Trauma PI: Peer-related Loop Closure (Part II)

Yesterday I wrote about loop closure in general and what it is. Today I’ll cover the specifics of peer-related performance improvement issues and how loop closure works with them. 

A peer-related issue typically involves a single trauma professional. In most cases, this is a physician, but may be a nurse, PA or other provider as well. These issues are most often related to care delivered to a single patient. 

The trauma program can identify a peer-related issue in a number of ways, including (with examples):

  • PI filter – delay to laparotomy by a surgeon
  • Complication – intestinal anastomosis breakdown
  • Resuscitation video review – nonsterile insertion of urinary catheter by a nurse or tech
  • Word of mouth – “Geez, it took forever to get blood from the blood bank!”
  • and many more!

Once identified, a “paper trail” must be started that documents the specific issue and the details of how it was found. This can be on a paper PI form, or an entry in your PI or trauma registry software package. The key is that you need to be able to track the progress as long as the issue is “open.”

Next, a determination is needed as to how the particular issue needs to be resolved. For physician items, that may occur via a group meeting (e.g. M&M conference) or a one on one meeting with an appropriate department leader (e.g. trauma medical director). For nursing items, each hospital typically has its own procedure (e.g. meeting with nurse manager).

Once the specific provider has been “re-educated”, final documentation of the process must be prepared. This may include a portion of the M&M meeting minutes or a letter or email message detailing the specifics of the discussion or retraining. All of the documentation collected, from opening of the PI issue to closure, must be preserved in a “folder” associated with this patient (remember, paper or electronic). Furthermore, an entry should be made in the credentialing file for the provider so that these items can be discussed in their annual review.

Here’s a specific example: a surgeon admits a patient with a CT-proven Grade IV splenic laceration. Although hemodynamically stable at first, they have frequent drops in blood pressure in the ICU that respond to crystalloid and several units of blood. After 6 hours of pressures dipping into the 70s and 3 units of blood, the blood pressure finally drops to 50 and won’t come back up. The surgeon takes the patient to the OR and performs a splenectomy. The patient recoveries, but remains on the ventilator for 5 days because of the large volume resuscitation that was given.

The delay to laparotomy PI filters are triggered, and the TPM and TMD place the issue on the Trauma M&M conference agenda. After discussion with all the faculty, the determination is that the patient should have gone to the OR after the first pressure drop in the OR. It is believed that the number of ventilator days would have decreased significantly as well. The delay is deemed a preventable complication. The TMD dictates the meeting minutes, detailing the specifics of the discussion, and noting that the involved surgeon was present. 

The final folder for the patient will contain documentation of the filter violation, a copy of the minutes from the M&M conference, and a copy of the short memo dictated by the trauma medical director that was placed in the surgeon’s trauma credentialing file.

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Please send questions you may have so I can discuss on Thursday and Friday!

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