Category Archives: Performance Improvement

Performance Improvement

Overtriage And Anti-NFTI

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In my previous post, I discussed the evils of undertriage and how we can use registry tools to decrease the number of charts reviewed to identify this problematic issue. Now, I’ll move to the opposite extreme: overtriage.

Overtriage is defined as summoning the trauma team when a patient does not meet any criteria for the given activation level. Granted, all trauma centers include a garbage collection criterion, clinician judgment, that lets them activate if criteria are not met, yet they have a bad feeling about the situation. This is a legitimate criterion and recognizes that intangible “gut feeling” trauma professionals may get in certain circumstances.

Overtriage is not as bad as undertriage. The patient is not at risk of life-threatening injuries being missed or treated late. But unneeded trauma activations do take their toll. Every activation summons a large team of people and relies disproportionately on personnel who have other jobs in the emergency department. Each unnecessary activation pulls people away from their other responsibilities for a period of time and disrupts the department’s overall workflow.

Sometimes, overtriage can be allowable. If there is regular personnel turnover on the trauma team, a few extra activations here and there can serve as training exercises. This can be important in trauma centers with trainees and higher nursing turnover. But taken to an extreme, it can wear everyone down, including the trauma surgeon.

There is an extreme case, which I refer to as “ultimate overtriage.” This involves a patient who triggers any level of trauma activation, undergoes a complete evaluation, and then is sent home (in paper clothes) several hours later. Sure, this may happen from time to time. But if it’s a regular occurrence, there is a problem.

I previously wrote about using NFTI (Need For Trauma Intervention) to help identify potential undertriage if patients required certain critical resources. Ultimate overtriage patients are just the opposite. They are anti-NFTI. They didn’t need any of those resources.

As the percentage of anti-NFTI overtriage cases climbs, so does the wear and tear on the trauma team. Typically, the number of highest-level activations is roughly 10% of registry admissions. The number of intermediate-level activations is usually about 25%. But some centers have more total trauma activations than they have trauma admissions! This is clearly a problem!

An ultimate overtriage problem is usually due to poorly designed intermediate-level activation criteria. Typically, there is an over-reliance on mechanism-of-injury criteria. Potential offenders are:

  • Use of vague qualifiers such as “high-speed”
  • Inclusion of vehicle intrusion criteria
  • Upgrading all patients over age xx (e.g., 65) to an activation based on fall or head strike
  • Vague fall criteria

What to do: First, see if you have a problem. Divide both the number of highest and intermediate-level activations per year by 365 to determine how many of each occur every day. Do the numbers seem reasonable? Most medium-volume centers will have one-ish highest-level and two-ish intermediate-level activations per day. If you are approaching five intermediates per day, you may have a problem unless you are very high-volume.

Next, run a simple registry report. For each activation level over a year-long period, list the total number and the number that were discharged home from the ED. Both percentages should be in the low double-digits. I have visited centers with more than 60% of level 2 activations sent home!

If you determine you have a problem, it’s time to review your activation criteria critically. Either retrospectively or prospectively, look at all trauma activations and identify which criterion was used to trigger it and whether the patient was sent home afterward. Keep a tally. Eventually, patterns will emerge. Some criteria will be completely nonproductive and should be reworked or, preferably, dropped. Do this slowly and carefully over time, and give your trauma team a break!

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Performance Improvement

NFTI: A Nifty Tool To Replace The Cribari Grid?

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This two-part post will examine trauma activation triage tools. The type of triage I am discussing is not prehospital triage. In this case, it involves ensuring that a trauma activation occurs appropriately and that the trauma resuscitation team evaluates the right patients.

The Cribari grid was the mainstay for years, using a high ISS score as a surrogate for appropriate triage. But it has shortcomings. The most important one is that it relies solely on the Injury Severity Score (ISS) to determine whether a type of mistriage occurred.  As you know, the ISS is usually calculated after discharge, so it can only be applied after the fact.

A few years ago, the Baylor University in Dallas group developed an alternate method of determining who needed a full trauma team activation. They chose resource utilization as their surrogate to select these cases. They reviewed 2.5 years of their registry data (Level I center).  After several iterations, they settled on six “need for trauma intervention” (NFTI) criteria:

  • blood transfusion within 4 hours of arrival
  • discharge from ED to OR within 90 minutes of arrival
  • discharge from ED to interventional radiology (IR)
  • discharge from ED to ICU AND ICU length of stay at least 3 days
  • require mechanical ventilation during the first 3 days, excluding anesthesia
  • death within 60 hours of arrival

Patients who had at least one NFTI criterion were considered candidates for full trauma activation, and those who met none were not. Here are the factoids for this study:

  • There were a total of 2260 full trauma activations and 2348 partial activations during the study period (a little over 900 per year for each level)
  • Roughly 2/3 of full activations were NFTI +, and 1/3 were NFTI –
  • For partial activations, 1/4 were NFTI + and 3/4 were NFTI –
  • Only 13 of 561 deaths were NFTI – and all had DNR orders in place

The authors concluded that NFTI assesses anatomy and physiology using only measures of early resource utilization. They believed that it self-adjusts for age, frailty, and comorbidities, and that it is a simple and effective tool for identifying major trauma patients.

Bottom line: NFTI has become a valuable adjunct to the Cribari grid. Both decrease the number of charts that must be manually reviewed to identify true undertriage. Cribari does this by using ISS as a surrogate for the need for the trauma team; NFTI does it using key resource utilization. Combining the two can further reduce chart reviews, saving a significant amount of PI analysis time.

In my next post, I’ll review a problematic subset of inappropriately triaged patients whom I refer to as “ultimate overtriage.” These are patients for whom the trauma team may not have been needed. And I’ll show you how these may be labeled as “anti-NFTI” patients.

Reference: Asking a Better Question: Development and Evaluation of the Need For Trauma Intervention (NFTI) Metric as a Novel Indicator of Major Trauma. J Trauma Nursing 24(3):150-157, 2017.

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Performance Improvement

The Value Of Audit Filters In Trauma Performance Improvement

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I recently read a paper in Trauma Surgery and Acute Care Open questioning the relationship between trauma audit filters and opportunities for improvement (OFI). Having concentrated on performance improvement for decades, I was taken aback by their conclusion that no individual or combination of filters performed well in predicting OFIs in their trauma patients.

Since their conclusion is in stark disagreement with my impressions of the value of audit filters, I, of course, had to read the paper in its entirety to see where my thinking had gone wrong. Or theirs.

Researchers in the Emergency & Internal Medicine and Public Health departments at Karolinska University Hospital conducted a retrospective review of 10 years of registry data on audit filter usage and subsequent opportunities for improvement identified at their morbidity and mortality conferences. These are the equivalent of the multidisciplinary trauma PI committees found at US trauma centers.

They found that the filters they studied had poor sensitivity and positive predictive value. The filters were:

  • SBP<90
  • Death within 30 days
  • ISS>15 and no trauma activation
  • Massive transfusion
  • GCS<9 without intubation
  • ISS>15 and not admitted to ICU
  • >60 minutes to first major intervention
  • >30 minutes to first CT
  • Liver or spleen injury
  • No anticoagulants within 72 hours after TBI

Without deeper reading, the authors imply that using static filters like these is of little value and that new tools should be developed.

Of course, I have to disagree. There are several issues here.

  • The trauma morbidity & mortality conference (or multidisciplinary trauma PI committee in the US) should not be the only level of PI analysis. It was not clear if there were corresponding primary review or secondary review processes at this hospital. If every case with a filter violation is sent to the committee, there will undoubtedly be many that are uninteresting and would have been filtered out at our lower levels of review.
  • I worry that this M&M conference is focusing only on the patient in question. The goal of any PI review is to help protect the next similar patient. They may not tolerate the relatively minor care issues that the current patient did.
  • It’s important not to focus only on patient harm. Many audit filters flag items associated with potential process problems. There is no guarantee of finding an OFI. The “greater than 60 minutes to first intervention” filter is a good example. Most of the time, deeper analysis will identify legitimate reasons for the delay. But the entire process must be dissected to ensure there weren’t any opportunities for improvement that need to be addressed. Most patients will suffer actual harm from the issue. But some could.
  • Trauma PI focuses more on high acuity, low occurrence events. Pulmonary embolism is rare but potentially deadly, so we devote a lot of time trying to streamline our systems for providing adequate and timely VTE prophylaxis. Thus, there will be a lot of PI “overtriage,” leading to low sensitivity and positive predictive value. It’s the price we pay to try to eliminate these “never” events.

Bottom line: In my opinion, audit filters offer a checklist of shortcuts that may identify potential opportunities for improvement. A filter violation does not guarantee that we will find anything. It doesn’t matter if the patient did well or did poorly. We certainly learn important lessons when the eventual outcome is suboptimal. But we can learn just as much by finding irregularities in care that caused no harm in this patient. It might for the next one.

A key filter that I use is something I call the grandmother test. Would I be happy if my grandmother (or my child or spouse) received this care? If not, it needs to be scrutinized even if this patient went home happy and well.

Reference: Performance of individual audit filters in predicting opportunities for improvement in adult trauma patients. Trauma Surgery & Acute Care Open. 2025;10:e001808. https://doi.org/10.1136/tsaco-2025-001808

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Performance Improvement

Autopsy Reports and Performance Improvement

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Autopsy reports have traditionally been used as part of the trauma performance improvement (PI) process. They are typically a tool to help determine opportunities for improvement when reviewing mortality 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 previously included a question on what percentage of deaths at a trauma center undergo autopsy, but this was discontinued with the 2022 standards. Low rates were usually discussed further, and strategies for improving them were considered. But even though autopsy review rates are no longer scrutinized, are they 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.

Here are the factoids:

  • 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 1 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 numerical performance improvement standpoint, autopsy did 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. And it may modify some of the diagnoses recorded in the trauma registry.

Anecdotally, I have received reports that opened my eyes to significant opportunities for improvement. I would still recommend obtaining the reports and performing at least a cursory review for their educational value, especially for those of you who are part of residency training programs.

Reference: Dead men tell no tales: analysis of the utility of autopsy reports in trauma system performance improvement activities. J Trauma 73(3): 587-590, 2012.

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Performance Improvement

How To “Track And Trend”

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One of the most overused terms in trauma performance improvement is “track and trend.” It implies that the event in question will be closely monitored, with the promise of potential future action.

But the reality is that, much of the time, these events are largely ignored, and a running tally is either kept somewhere or will be calculated at some undefined time in the future. The ultimate result is that these events tend to get “swept under the rug” and ignored.

All is not lost! If done correctly, “track and trend” can be very valuable.  Here are the key components of an effective “track and trend” process:

  • A definition of the problem event. Be very specific. For example, the occurrence of VTE interruption in patients with orthopedic injuries requiring surgery.
  • Occasionally optional: An intervention that has been implemented to address the event and make it “better.” If you have experienced what you believe is a truly one-off event and want to confirm its rarity, an intervention is not necessary. However, this is not a common occurrence. Most events will require some type of intervention, especially if they are serious or seem to be recurring.
  • A length of time for monitoring. Again, be specific. The length of time must be based on the specific event being tracked. Sometimes the time frame may be brief, e.g., three months. But in this VTE example, a longer time may be required, such as a year.
  • A threshold goal. This is the new minimum acceptable performance standard. It will be dependent on the event being tracked.  Sometimes, guidance can be found in the literature. But most of the time, the current incidence will need to be calculated, and then reduced by an arbitrary amount to arrive at the new threshold. In this example, if the current incidence is 20%, the program may want to drop it to 10%.

In this example, the full “track and trend” text reads like this:

We will track the occurrence of interruption of VTE chemoprophylaxis in patients undergoing operative repair of orthopedic injuries after implementing a new VTE practice guideline. This will be monitored for 12 months, with a goal of an incidence of less than or equal to 10%.

Here is another example. A trauma surgeon took a hypotensive patient to CT scan during a trauma activation, where the patient suffered a cardiac arrest due to inadequate resuscitation. The PI process captured this, and the TMD counseled the surgeon.

Here’s the track and trend text in this case:

After counseling by the TMD, we will track the occurrence of hypotensive patients being taken to CT during trauma activations by Surgeon X for six months, with a goal of no occurrences during that period.

The final part of the track and trend process is to see if the goal was met. If so, create solid documentation for loop closure, and your job is done! If not, it’s time to put on your thinking cap, change the intervention, and start again. Repeat until the final goal is reached.

By implementing this process, the track and trend process can actually be a meaningful part of the PI program.

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