Tag Archives: performance improvement

Trauma PI: Chasing Rumors

Trauma performance improvement (PI) is part art and part science. I tend to segregate the process into 3 segments: inputs, processing, and outputs. There are lots of possible inputs, including violation of specific audit filters (too long to OR, open fracture delay, etc.),  referrals from M&M discussions, incident reports and video reviews of trauma resuscitations, to name a few.

There is one PI input that has the potential to be a problem, though: word of mouth. You know, someone tells the trauma program manager that things just didn’t go well during that last trauma resuscitation. This is a perfectly legitimate way to identify PI issues. However, “word of mouth” can be categorized by source into “identified” and “anonymous." 

Word of mouth sources that are identified are not a problem. Anonymous ones are. All too often, these unsigned notes or suggestion box drops or phone messages are initiated by someone with an axe to grind. Most of the time, there is no basis for the incident that has been reported. The PI program can spend lots of time and energy trying to track down these perceived "problems”, and nothing ever comes of it.

There are two major problems with unsourced word of mouth “tips”:

  • There is no way to get additional information about the event from the source
  • It is not possible to thank the source for the information and let them know what was done to correct the issue

Bottom line: Performance improvement “tips” from anonymous sources are usually unfounded and a waste of time to investigate. Let it be known that your PI program is happy to receive written or verbal notices of potential problems that need to be pursued. However, every request must have a name and contact number and/or email included or it will be discarded.

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AAST 2011: Autopsy Reports and Performance Improvement

Autopsy reports have traditionally been used as part of the trauma performance improvement (PI) process. They are typically a tool to help determine preventability of death in cases where the etiology is not clear. Deaths that occur immediately prior to arrival or in the ED are typically those in which most questions arise.

The American College of Surgeons Trauma Verification Program includes a question on what percentage of deaths at a trauma center undergo autopsy. Low numbers are usually discussed further, and strategies for improving them are considered. But are autopsies really that helpful?

A total of 434 trauma fatalities in one state over a one year period were reviewed by a multidisciplinary committee and preventability of death was determined. Changes in preventability and diagnosis were noted after autopsy results were available. The autopsy rate was 83% for prehospital deaths and 37% for in-hospital deaths. Only 69% were complete autopsies; the remainder were limited internal or external only exams.

Addition of autopsy information changed the preventability determination in 2 prehospital deaths and on in-hospital death (1%). In contrast to this number, it changed the cause of death in about 40% of cases, mostly in the prehospital deaths.

Bottom line: From a purely performance improvement standpoint, autopsy does not appear to add much to determining preventability of death. It may modify the cause of death, which could be of interest to law enforcement personnel. I would still recommend obtaining the reports for their educational value, especially for those of you who are part of training programs.

Reference: Dead men tell no tales: analysis of the utility of autopsy reports in trauma system performance improvement activities. AAST 2011 Annual Meeting, Paper 63.

Timed PI Audit Filters: When Does The Clock Start?

Several of the performance improvement (PI) audit filters typically used at trauma centers include a time parameter. These include:

  • Craniotomy > 4 hrs
  • Laparotomy > 4 hrs
  • OR for open fracture > 8 hrs
  • Compartment syndrome > 2 hrs

The question that needs to be asked is: 2 or 4 or 8 hours after what?

There are several possible points at which to start the clock:

  • Arrival in the ED
  • When the diagnosis is made
  • When the decision to operate occurs

The answer is certainly open to interpretation. Here is my opinion on it:

The purpose of a PI filter is to measure system performance. There are a myriad of system problems that can delay taking a patient to the OR. These include care delays in the ED, delays in getting or interpreting diagnostic tests, delays in contact or response for consultants, delays in diagnosis, delays in OR scheduling or availability, and more. Does it make sense to limit the evaluation of your system by setting one of the later decision points as your start time?

Bottom line: I recommend starting the audit filter clock at the time of patient arrival in the ED. This enables the PI program to evaluate every system that can possibly enable or impede your patient’s progress to the OR.

Trauma PI: When Is A Peer Issue Really A System Issue? (Part IV)

Yesterday I discussed loop closure for system issues. Today I’ll look at the interesting relationship between peer and system issues.

Although most PI issues that arise seem to be related to something done (or not done) by an individual, that doesn’t mean that the issue is peer-related. Frequently a significant portion of the problem is caused by a system issue. How can this be?

Let’s take the example of DPL. A physician performs a DPL in the trauma bay and the trauma PI program notes that it was performed without the requisite placement of an NG tube and urinary catheter first. At first look, this is a peer-related problem, right? Just counsel the doctor and everything will be better.

Wrong! Your PI program needs to assume that every apparent peer-related problem is a manifestation of one or more system issues. In my example, another DPL is performed 6 months later by a different physician, and once again the catheters are not inserted first. What gives?

I recently wrote that DPL was a dying art. Most institutions perform this procedure only a few times a year. People get rusty with uncommon procedures because they can’t practice. So instead of considering this a physician problem, look at it as a system problem. How can you keep them from forgetting something they seldom do? Simple! Attach a gastric tube and a urinary catheter directly to the DPL kit. When the physician grabs the kit, they will be instantly reminded of the need to insert them first. Problem solved.

Bottom line: always assume that people are doing their best to provide excellent care to their patients. Look closely for possible system problems that are keeping them from doing just that. Then put your thinking cap on and come up with some creative solutions.

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Trauma PI: System Issue Loop Closure (Part III)

Yesterday I discussed loop closure for peer-related issues. Today I’ll delve into loop closure for system issues.

System issues are those that tend to involve multiple patients. They are not as easy to identify, because it may take a while for you to see a problem pattern emerging. And they are definitely harder to fix because they require a multi-faceted problem solving approach.

Here’s an example: You are presenting a complication (pulmonary embolism) in your trauma morbidity and mortality (M&M) conference. One of your colleagues notes that this is the third such presentation this year, which seems to be higher than previously. And come to think of it, the number of deep venous thrombosis presentations seems to be higher as well. 

You ask your trauma registrar to run some reports on these complications, and you find that the incidence of both in your trauma patients has increased 80% over the previous year! Time to put on your thinking cap, review the literature and critically look at your care and what other centers are doing. You conclude that your trauma patient population hasn’t changed, but that your DVT surveillance and prophylaxis are spotty and vary considerably by physician.

Your solution consists of a new protocol or practice guideline that 1) identifies the risk level for each trauma patient, 2) defines what prophylactic measures will be used based on the risk assessment, and 3) determines what kind of screening will be done and how often. This protocol is implemented by your trauma operations committee, with all trauma physicians instructed to use it. It is monitored by your trauma program staff, and regular scorecards are sent to each physician. Regular reports detailing physician compliance and patient complications are made at each M&M or Trauma PI Committee meeting as well.

Six months later, registry data is reviewed again and you find that the incidence of DVT has decreased (but not to baseline because you are screening better and finding more), and the number of pulmonary emboli has dropped nearly to zero. Problem solved? Maybe. Periodic monitoring and continuation of the scorecard system is probably needed to make sure that the protocols are maintained.

What do you need to close the loop? You need a “folder” to save your information as I discussed previously. Since this problem involves many patients, it doesn’t fit as well into current registry packages that are oriented to single patient records. Whether your folder is paper or electronic, here are the items that need to be saved:

  • Minutes from the first M&M meeting where the discussion reflects the recognition of the problem
  • The registry reports that show the increasing incidence of the problem
  • The new protocol and scorecard that were developed, along with any tracking tools
  • The operations committee minutes showing approval of the protocol
  • Completed scorecards for the physicians
  • M&M minutes for meetings at which DVT/PE reports were given
  • Registry reports that show the decreased incidence of DVT/PE. You can consider the item closed at this point.
  • Any followup registry reports for monitoring done on a regular basis can be added to the folder later

As you can see, this is much more complicated than a peer issue. However, system issues show the value and strength of your trauma PI program. Trauma reviewers focus on how well you identify and address system problems because it is an indication of the maturity and power of your trauma program.

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