Traumatic Brain Injury Quality Improvement for Pre-Hospital Providers: A Pilot Project

Giles Gifford, EMT

Project Coordinator

Monica S. Vavilala, MD

Project PI

Giles Gifford, EMT

Paddy Downey, EMT

Traumatic Brain Injury (TBI)

Leading cause of morbidity and mortalityYearly 1.7 million people sustain TBI

~1.36 million are treated in ED and discharged 275,000 hospitalized80,000 to 90,000 disabled 52,000 die

5.3 million (~ 2%) are living with TBI disability~1% of severe TBI survive in a persistent vegetative state

In 2000, estimated lifetime direct medical costs and indirect costs (e.g., loss of life long productivity) from TBI = 76.5 billion dollars

National TBI Guidelines

BTF (2007)Evidence based guidelines for severe TBI carePre-hospital componentPre-hospital care assessment, treatment and transport

guidelines separated into 7 areas (ALS and BLS) PHTLS

One didactic chapter

TBI Care Protocols in WA StateNo state TBI protocol specific for TBI

Two EMT-B (BLS) protocolsAdherence required by DOH for all 39 counties

General trauma assessmentHead and spine injury

No standard EMT-P (ALS)County MPD decides protocols for assessment,

treatment and transport

Current WA State CME State

DOH has EMT-B protocols in placeCounty

MPD decides how EMTs maintain certification OTEP – Ongoing Training and Evaluation Program

Competency based - no set number of hours per year Series of topics (Cardiac, OBGYN etc.) Given by MD or certified trainer in person or video recording Cognitive/written exam Practical portion to demonstrate proficiency

EMS online – online educational modules with case studies, written exam and in person practical skills assessment

Accreditation EMTs must recertify every 3 years

No current TBI module

ProblemsNo uniform guidelinesPre-hospital educationLack of benchmarking

Adherence to national guidelines unclear

HIPRC AimsExamine current TBI EducationPresent techniques to improve TBI care

Project Overview

Year 1 (2010-2011): Benchmarking and Education Do we adhere to national guidelines in WA State ? Can we develop a training module for state ?

Year 2 (2011-2012): Development and Pilot TBI QI Bundle What TBI QI processes exist nationally ? Develop the QI bundle (module, documentation, cases) Pilot the QI bundle Evaluate QI bundle effectiveness

BTF Guidelines Yes(n=23)

No(n=23)

Some(n=23)

Monitor for hypoxemia (SpO2 < 90% )

2 (9%) 9 (39%) 12 (52%)

Monitor for hypotensionSBP < 90 mmHg for age > 13 yrs

4 (17%) 8 (35%) 11 (48%)

Assess oxygenation every 5 min.Continuous monitoring if possible

1 (4%) 14 (61%) 8 (35%)

Assess BP every 5 minutes.Continuous monitoring if possible

1 (4%) 12 (52%) 10 (44%)

County Adherence:Oxygenation and Blood Pressure

Total counties = 397 No ALS providers, 9 No TBI elements

Year 1 Summary

1. Benchmarked WA State ground, county ground, and air ambulance protocol language and content

2. Learned pre-hospital providers want more TBI education

3. Delivered1. ppt module to DSHS for dissemination

2. DOH approved module for CME

3. Module posted on EMS online

4. Module posted on HIPRC website

Year 2 Aims (2011-2012)Develop TBI QI bundle

1. Educational module2. Score PCRs using TBI audit tool3. In –person case discussions

Pilot and Evaluate TBI QI Bundle1. 2 rural and 2 urban counties2. Outcomes

1. Change in PCR documentation of TBI indicators pre and post bundle

(audit score) Pre and post education test score (knowledge)

2. Pre-hospital provider satisfaction

Evaluation of WA State Pre-Hospital QI Process

No written template for QI process

QI at county level, under MPD directionBoard

5-6 members selected by MPDs ER nurses, paramedics and other physiciansConfidentiality agreement

Meets 1 to 2 times/ year to review EMS patient care reports (PCR's) focusing on area of review

Development of Audit Tool

Research existing written pre-hospital TBI QI processes Internet search of state, county, municipality protocols USFound 4 with written templates addressing some TBI

elements NY (State), CA (County), PA (Pittsburgh), FLA (Miami)

Selected “poorly faring or important” WA state indicators for benchmarking

20 Audit Tool Indicators:

Mechanism of injury• Antecedent events• Kinematics• Witness accounts

TBI signs and symptomsLoss of consciousnessSerial Vital Signs - Q5 Serial GCS scores – Q5Pupillary exam – Q5ETOH/ drug use

C-Spine precautionsHypoxia preventionIntubation indicatorsSerial capnography valuesPost intubation RR IV fluid initiationGlucose valueTransport decisions

14

Score 1 = complete documentation of indicatorMaximum = 20 ALS, 16 BLS, 11 No Transport

Recruitment of CountiesWEMSIS considered

Electronic data capture with pre-collected indicators of “head trauma” System capabilities and state contributions

Direct recruitment MPD list of contacts

Email invitation Phone project introduction Scheduled in person training

QI Bundle Before training, each MPD sent ~20 PCRs to HIPRC Training

1. Audit tool introduction2. Baseline county results3. Pre-test 4. Education module5. Case study6. Post test7. Satisfaction survey

Second set of PCRs due 6 months after training

Email List to 39 County MPDs

County Enrollment

Response Rate (n=15; 38%)

Phone Call (n=11; 28%)

Sent PCR’s & Scheduled Training (n=10; 26%)

Training Complete (n=10; 26%)

PCR Review Sample84% electronic16% paperElectronic PCRs more

indicators than paperPaper PCR

Too much free textData fields not

prompted

PCR ReviewAssociated with picturesMay be helpful to understanding mechanisms

Total ScorePossible: 20

Total ScorePossible: 16

Total ScorePossible: 11

198 PCRs From 10 Counties (2008-2011)

• Room for improvement

To

tal

Sco

re P

oss

ible

Number of 10 Counties with Poor (0-49%) Documentation on PCR (n= 198)10: GCS reassessed every 5 minutes 10: Pupil reassessment 9: VS reassessment every 5 min 9: Glucose check 9:Capnography used after ETT with serial readings 8: Pupil examination with component parts 5: ETT ventilation rate supported3: ETOH or drug use 3: Post tracheal intubation RR documented2: Completed vital signs1: GCS with component parts

Outreach: Module & Case Discussion12 site visits to 10 counties:

2 counties requested 2A total of 190 EMS personnel attended:

County MPD, all EMT levels, county training coordinators, ER triage nurse, county EMS directors

Pre & Post Training Quiz

1. Same 10 question quiz to assess effectiveness

2. Questions based on need Signs & symptoms (3) GCS (3) Ventilation (2) Cerebral herniation (1) Transport decisions (1)

3. Satisfaction survey

P < 0.0001

Overall Pre and Post Test Score Change

Question 6 - GCS

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Total

Pre-test ~ 8% Post-test ~ 89%

Scor

e

(True/False) “Squeeze my hands” counts as obeying a verbal command

Question 8 - Ventilation

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Total

Pre-test ~ 17% Post-test ~ 73%

Scor

ePatient presents with extensor posturing, fixed dilated pupils, SpO2 90%, EMT –P should:

A) Intubate and hyperventilateB) Intubate and normoventilateC) Administer 25 Liters/min. non-rebreather mask

Documented Improvement

Signs and symptoms scores increased for all questions GCS familiarization increased for all questionsCerebral herniation recognition increased by 9%Knowledge of appropriate transport decisions increased 10%

55%-81%

55%-86%

49%-78%

Change in Test Scores By County

57%-79%

62%-78%55%-71%

46%-73% 61%-72%

73%-88%

55%-57%

= Counties with greatest improvement

Follow up with MPDs

Emailed 1. Audit scores a week after site visit

2. Training module

3. Audit tool for use

Training Satisfaction (n = 190)

= Yes = Neutral = No = No Response

Comments from EMS and MPDEMTs

Good to stress GCS scores because they don’t get used enough Great review and good reminders of what we need to be looking for

Always a good thing to review and keep current on, great job Very informative and provided new thoughts about head trauma QI audit tool is a good tool to add to the patient report chart

MPDs Practical aspect to training BLS to ALS Handoff No N/V, dizziness stressed in training

Year 2 Lessons Learned 1. Counties want this training (recruited 10, not 4)

2. Pre-hospital setting may benefit from a QI process

3. MPDs are willing to participate

Next Steps

Obtain follow up PCRs from counties Filter these reports through audit toolReport areas of improvement

Especially in areas with low adherence Publish process and findings Dissemination and Implementation study

3:20 – 4:20 Traumatic Brain Injury, Patty Downey 1. TBI is a leading cause of morbidity and mortality in

Washington State. 2. EMS of all levels play an important role in the detection

and treatment of TBI. 3. Early recognition and timely management of TBI by

emergency medical personnel is essential 4. Please join us for a CME training based on the Brain

Trauma Foundation’s guidelines for the prehospital TBI management

Acknowledgements of Study Partners

AgenciesDSHS DOHBIAWWEMS On-lineState Counties

PeopleMike LopezKathy SchmidtTerry RedmonDeborah Crawley Deepak SharmaCharles MockEileen BulgerMickey Eisenberg

Acknowledgements of Participating County MPDs & Staff

Dr. Sandra Smith-Polling Steve Gordon Palmeroy Colleen Rodriguez

Dr. Michael LuceRichard Naumann

Dr. Russell SmithMark BryanBob Gwynn

Dr. Marvin WayneSean Farnand

Dr. Terry MurphyDr. Lance Jobe

Rinita Cook

Dr. Don SlackDr. Patrick O’NeillDr. Michael Sullivan

Mik PreyszPatrick Shelper

Last slide

Results for Oxygenation and Blood Pressure Across all 7 BTF Indicators

• State level EMT-B protocol (n=1): • 2 indicators partially matched• 5 did not match

• % Counties of n=23 that matched on 7 BTF indicators: • Fully= 0-17%• Partially = 0-48% • None = 35-100%

Year 1: Pre-Hospital Focus Group Results

Current CME methods well likedMost EMTs they had knowledge of triage/transport criteria50% felt adequately prepared to treat TBI but were not

familiar with their county protocolWanted more education on

Secondary insults  GCS Elderly needs Symptom recognition Altered LOC ETOH Concussion

Year 1: Module Development

ALShttp://depts.washington.edu/hiprc/Education%20and

%20Training/EMS%20Training%20Module/PART3-A.ALS.PPT.pdf

BLShttp://depts.washington.edu/hiprc/Education%20and

%20Training/EMS%20Training%20Module/Part3-B.BLS.PPT.pdf

County Risk PCR –No TransportX/11

PCR -BLSX/16

PCR –ALS NO ETTX/17

PCR – ALS ETTX/20

PretestAverage

Posttest Average

Whatcom High 5.8/11 n=6

7.6/16 n=7

11.6/17 n=10

13.2/20 n=6

57% 79%

Skagit High N/A N/A 11.8/17 n=17

10/20 n=3

61% 72%

San Juan Low 4.4/11 n=9

10.5/16 n=1

12/17 n=9

17/20 n=1

46%

73%

Jefferson High 5/11 n=1

11.5/16 n=2

11.2/17 n=11

13/20 n=7

62% 78%

Chelan Low N/A N/A 13.1/17 n=7

13.3/20 n=5

55% 57%

Douglas Low N/A N/A 13.1/17 n=7

13.3/20 n=5

55% 71%

Grant High N/A N/A 12.3/17 n=20

15.1/20 n=4

55% 81%

Lewis High N/A 4.5/16 n=1

11.1/17 n=17

14.7/20 n=5

73% 88%

Klickitat Low N/A 10.7/16 n=3

11.8/17 n=13

14.5/20 n=2

55% 86%

Columbia Low N/A 10.8/16 n=12

12.1/17 n=6

8/20 n=1

49% 78%

Year 1 Aims

1. Examine WA state language and content adherence to national guidelines for severe TBI

2. Examine needs and opportunities for pre-hospital TBI education

3. Develop a pre-hospital curriculum for TBI in WA state

Year 1 Methods

Benchmarking against 7 BTF areas, each with multiple recommended indicators

1. Assessment: Oxygenation and Blood Pressure2. Assessment: Glasgow Coma Scale Score3. Assessment: Pupil Examination4. Treatment: Airway, Ventilation and Oxygenation5. Treatment: Fluid Resuscitation6. Treatment: Cerebral Herniation7. Transport: Transport decisions

Focus groups, phone interviews and written surveys EMTs in each county BIAWW EMS conference

Educational module

Year 1 Benchmarking Results

Of 39 counties in WA State7 (18%) do not have any ALS protocols for anything9 (23%) have ALS but not specific “head trauma or

TBI” protocols23 (59%) have ALS and addresses “head trauma or

TBI” components

BTF Assessment Example: Oxygenation and Blood Pressure

• Each indicator compared with current WA State EMT-B TBI protocols, WA State county ALS TBI protocols and two private air ambulance companies

• Indicator adherence at the state, county and air ambulance company level

• Protocols grouped as meeting BTF guideline recommendations:

• All = meets all • Some = meets some• None = matches none

Part 1-B Literature ReviewA Pub Med search was conducted with key

words TBI and prehospital – 207 resultsExcluded results prior to March 2007Excluded editorialsPediatric and Animal studies excluded

7 studies remained relevant 6 had findings concurrent with the BTF

guidelines1 study advocated slightly different acceptable

PaCO2 levels

•Electronically written PCRPCR Review

•Every data field is prompted

PCR Review Results

Received 201 PCRs from 10 different counties

Lewis Co. n=22, range 28%-88%, median 66.5%Skagit Co. n=20, range 30% - 88%, median 65%Grant Co. n=24, range 59%-88%, median 71%Jefferson Co. n=22, range 53%- 88%, median 69%Whatcom Co. n=29, range 36%-81%, median 59%Klickitat Co. n=18, range 56%-88%, median 69%Columbia Co. n=19, range 40%-82%, median 69%Chelan & Douglas Co. n=24, range 48%-91%,

median 75%1 MPD for both counties

QI National ReviewUsing established Washington Emergency Services

Information System (WEMSIS) data base indicators and the BTF guidelines, a TBI QI Audit Tool was developed to evaluate EMS head trauma responses from participating agencies throughout the state.

This was compared nationally to other QI processes that included head trauma at the state, county and city government levels

At the State Level - New York has published the only comprehensive quality improvement document complete with sample audit tools.

California has QI Audit Tools and guidelines at the County level

EMS councils from the cities of Pittsburg and Miami have published QI Audit Tools and Guidelines

Question 1 – Signs and SymptomsThe following are signs and symptoms of ETOH and not Traumatic Brain Injury

A) Slurred speech, vomiting, loss of coordinationB) Dilated pupils, convulsions, diminished consciousnessD) All of the aboveE) None of the above

Question 2 – Signs & Symptoms

(True/False) Hypoxia and hypotension are recognizable and preventable causes of secondary brain injury?

Question 3 – Signs & Symptoms

(True/False) Tachypnea, tachycardia, change in level of consciousness, and cyanosis are all signs of shock but not hypoxia?

Question 4 - GCS

(True/False) – The motor component of the GCS focuses only on the upper extremities?

Question 5 - GCSWhat is the GCS score for a patient whose eyes open to pain, withdraws from painful stimuli, and makes inappropriate sounds?

A) 3 + 4 + 3 = GCS of 10 (moderate TBI)B) 3 + 3 + 3 = GCS of 9 (moderate TBI)C) 2 + 4 + 2 = GCS of 8 (severe TBI)

Question 7 - Ventilation

(True/False) Prophylactic hyperventilation - (PaCO2 < 35 mm Hg) should be initiated for every severe TBI patient

Question 9 – S&S Cerebral Herniation

All of the following are signs/symptoms of cerebral herniation exceptA) Dilated pupilsB) Extensor posturingC) Cyanosis of the fingernails and lipsD) Cushings Triad

Question 10 – Transport DecisionsPatients with severe TBI should be transported to a facility with immediately availiable

A) CT scanningB) Prompt neurosurgical careC) The ability to monitor ICPD) Two of the aboveE) All of the above

Training Satisfaction (n = 190)

Question 1 = Agree 2 = Neutral 3 = Disagree No Response

Did you find the training useful to your knowledge or practice?

115

(60%)

7

(4%)

9

(5%)

59

(31%)

Did you learn how to better assess treat or transport TBI patients?

105

(55%)

14

(7%)

11

(6%)

60

(32%)

Would you recommend this training to your colleagues?

111

(58%)

8

(4%)

11

(6%)

60

(32%)