One of the more poorly understood concepts in trauma performance improvement is the focus of the process. Are we really discussing the patient who had a quality issue?
I occasionally see something like the following in the published multidisciplinary trauma PI committee minutes:
“Although an opportunity for improvement was found, it was non-contributory and had no impact on patient outcome.”
Unfortunately, the true purpose of the committee discussion has been lost. The simple truth is that we are trying to learn from a patient we have cared for. None of the events or opportunities for improvement identified can impact them. Time has passed, and if there were any irregularities in their care, it is too late to fix them. For this patient.
However, the proper focus of the performance improvement program is to make things better for the next, similar patient. Here’s an example:
Scenario 1: An elderly patient presents after a fall with a mild head strike. They are awake and alert and present to a trauma center where this is recognized as a high-risk mechanism. A limited activation occurs, the patient is rapidly assessed, and she is whisked off to CT scan 20 minutes after arrival. The report is back in 10 minutes and shows a 1.5cm subdural hematoma with mild ventricular effacement.
Neurosurgery is rapidly consulted and sees the patient within 15 minutes. He plans an emergent operation. The patient is taken to the OR two hours later for a successful craniectomy and drainage. She does well and is discharged home neurologically intact four days later.
Everything looks great, right? Unfortunately, no.
This case could very easily be called a great save. But the patient’s identical twin sister comes in two weeks later with exactly the same presentation. What if the patient vomits, becomes unresponsive, and blows her pupils just one hour after the neurosurgeon sees her? They get a stat repeat CT, and the neurosurgeon now pronounces the larger lesion a non-survivable injury.
The second case will definitely end up being discussed by your multidisciplinary trauma PI committee as a death. Perhaps the one-hour delay is deemed acceptable because “that’s how we do it here” (shudder, a big red flag).
But what if the PI process picks up that two-hour delay in the first case and deems it suboptimal despite the rosy outcome? Processes are implemented to get an OR ready quicker and ensure the neurosurgeon’s availability. Now, a patient can theoretically be in the OR within 30 minutes of this “emergency” designation. When the second patient arrives two weeks later, this new process works flawlessly, and she, too, has a great outcome.
Bottom line: Your PI program is designed to protect the next similar trauma patient arriving at your center. Don’t forget that. Scrutinize care closely, even if the outcome was great and it’s exactly how you “normally” do it. Ask yourself if you would be satisfied if it were your spouse, parent, or child receiving that care. If not, fix everything that isn’t right. For all you know, that next patient could very well be your family member!
