Category Archives: Performance Improvement

How Often Should My Trauma Operations Committee Meet?

In my last post, I discussed how often your multidisciplinary trauma performance improvement committee (PI) should meet. As you know, one other mandatory committee is required of all trauma centers, the Trauma Operations Committee (Ops). In this post, I will:

  • describe how often your operations committee should meet
  • help you determine whether your two committees should meet on the same day or separately

How Often?

The short answer to this question is practically the same as for your PI committee, “it depends.” Whereas the PI committee schedule is determined more by the volume of your performance improvement activity, your ops committee is driven by its agenda.

First, look at what items are on your typical agenda:

  • Reports
  • Announcements
  • Policy discussion and revision
  • Marketing and outreach planning
  • TQIP report analysis
  • System issue analysis
  • Workgroup reports
  • Other stuff

Now, think back to your previous meetings. Do you sometimes have to cancel due to a lack of agenda items? Do you struggle to keep to the time allotted and frequently go over it? These are your biggest clues that let you know that you need to adjust the meeting frequency,

In general, your ops committee frequency is reasonably predictable from your trauma center level:

  • Level I – monthly
  • Moderate to high volume Level II – monthly
  • Lower volume Level II – bimonthly
  • Level III – bimonthly to quarterly
  • Level IV – quarterly

However, the agenda is really what drives meeting frequency. If you have a very active ops committee or are a “young” trauma center, this group may be very busy and need to meet more frequently than this. Base your final decision on your level of “busyness.”

To Combine Or Not Combine?

Combining your PI and Ops committee meetings has several pros and cons.


  • Decreases the number of meetings for everybody by one
  • Easier scheduling for attendees and venue
  • Consolidates agenda planning for the trauma admin team


  • May lead to loooong meetings
  • Frequently results in a less predictable start time for the second meeting
  • Requires extra administrative effort to maintain separate minutes and content
  • Often involves required attendees changing between meetings

Consider the logistics and personalities involved in your committees carefully. Do the attendees value shorter meetings with a predictable start time? Or do they just want to power through and take care of all of the business at hand?

Bottom line: First, determine the ideal frequency for your operations committee meeting. Is it the same as your PI committee? If so, consider combining them. If not, you will probably be forced to live with separate meetings. It is possible, however, to be creative. Consider a monthly PI meeting combined with the Ops meeting every other month.

What is the usual combined duration of the two meetings? If it is more than 2 hours, I recommend not combining them. That is just too long for your attendees to stay focused. If you can combine them, then look at the specific attendees for each meeting. Are they mostly the same? If they are, you are more likely to be successful when combining them. Reach out to your attendees to see if they would welcome a single meeting date and time. But warn them that it will routinely be 1.5 to 2 hours in length.

Now, plan your agendas carefully. If you have a substantial number of attendee changes between meetings, figure out how people will know when to show up for the second. It is easiest to have the smaller meeting first, and then add attendees when the second one starts. As for timing, there are two choices: always make each meeting a fixed length, or limit your first meeting to an exact length and allow the second to start at a fixed time and have a variable duration.

Finally, make sure the contents and minutes of the two meetings are separate. This keeps your documentation clean and easier to follow.

Print Friendly, PDF & Email

How Often Should My Trauma Multidisciplinary Performance Improvement Committee Meet?

Every trauma center is required to have two specific committees: a multidisciplinary trauma performance improvement committee (PI) and a trauma operations committee (ops).  However, a common question is, “How often do my committees need to meet?” Let’s start with your PI committee.

The answer, of course, is “it depends.” There is no cookie-cutter, one-size-fits-all answer. In this post, I’ll review the six factors you must consider when designing your meeting schedule.

Total Patient Volume

The number of patients seen at your center directly impacts your PI committee meeting schedule. The more patient encounters, the more likely that performance issues will arise and the more likely that some will need to be aired at the full committee meeting.

PI Issue Volume

What is the total number of PI items that your program identifies over time? Busy Level I centers may find five or ten items
every day!

In contrast, an average Level IV center may only find a PI issue to pursue every few weeks. This has a noticeable impact on how often these items need to be escalated, analyzed, and discussed at your PI meeting.

PI Issue Severity

What fraction of your PI cases actually require discussion by the full committee? How many can be processed and closed by the Trauma Program Manager alone (primary review) or with the Trauma Medical Director (secondary review)? Only complex cases that require the input of multiple liaisons actually need to go to the committee.

Alternate review pathways

There are more options for review other than the primary and secondary pathways mentioned in the previous paragraph. Typical options would be direct correspondence with a liaison for simple one-service issues or discussion (and good documentation) from a morbidity and mortality conference. The use of these alternatives will reduce the number of potential cases for your PI committee and decrease the overall number of meetings needed.

Age of your Trauma Program

Are you part of a mature, long-standing trauma center? Or is your program newly minted by the American College of Surgeons or state designating agency? Newer centers benefit from sending more items to the PI committee to build engagement of the liaisons and other attendees. More frequent meetings help get them used to the review process and the frank but friendly discussions required for effective PI review.

PI Committee “Leftovers”

How often do you need to table issues or cases until the next meeting because you ran out of time? If you are chronically short of time to discuss all the agenda items, it’s time to either make the meeting longer (groan!) or schedule them more frequently.

Bottom line: These six factors listed above must be considered when choosing your meeting schedule. Here are my starting suggestions for the ideal frequencies for adult trauma centers:

  • Level I – monthly
  • Moderate to high volume Level II – monthly
  • Lower volume Level II – bimonthly
  • Level III – bimonthly to quarterly
  • Level IV – quarterly

Most pediatric centers admit lower volumes and less complex patients, which usually only warrants a bimonthly meeting.
Remember, these are starting meeting frequencies only.
If you are a new trauma center, consider more frequent meetings for your first year to get your attendees used to and invested in the process. And if you need more cases to fill the meeting or have more hold-overs until the next meeting, adjust your calendar appropriately.

In my next post, I’ll cover this same topic for your trauma operations committee.

Print Friendly, PDF & Email

NFTI And STAT: Can They Replace The Cribari Grid?

In my last post, I reviewed using the Cribari grid to evaluate over- and under-triage at your trauma center.  This technique has been a mainstay for nearly two decades but has shortcomings. The most important one is that it relies only on the Injury Severity Score (ISS) to judge whether some type of mistriage occurred.  The ISS is usually calculated after discharge, so it can only be applied after the fact. And its correlation with outcomes varies.

What is NFTI, Exactly?

Five years ago, the Baylor University in Dallas group sought to develop 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 three days
  • require mechanical ventilation during the first three 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 if an activation did not occur, the encounter would be regarded as undertriage. On the flip side, if no NFTI criteria were present and an activation did occur, it would be overtriage.

The First NFTI Paper

In their first published paper, the Baylor group analyzed nearly 5,000 trauma activations, split roughly in half for full versus partial trauma activations. Two-thirds of the full activations met at least one NFTI criterion. This means that about a third might be considered overtriage since they did not require one of the critical resources or die within 60 hours of arrival. And looking at the partial activations, fully 75% did not meet any NFTI criteria. There were 561 deaths in the overall group (12%). Of those, only 13 did not meet any NFTI criteria, but every one had a DNR order in place.

Now let’s translate all this into under- and overtriage numbers:

  • Undertriage: 22% (partial activations that were NFTI +)
  • Overtriage: 58% (any level of activation in a NFTI – patient)

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

But is it better for evaluating over- and undertriage than the Cribari grid? I’ve had several people tell me that it is. But if you look at the numbers above, overtriage is in the usual range, and undertriage is higher than the usual raw Cribari numbers. Even the authors suggest that it might be used to determine if the patient needed a trauma activation. Up to this point, NFTI is interesting, but not better than Cribari on its own.

The following year, these authors published a paper that further refined their concept. They rolled NFTI into something called the Standardized Triage Assessment Tool (STAT). Basically, the Cribari matrix is applied to the trauma activation data as usual. The fallouts (over- and undertriage groups) are then tested against the NFTI criteria. Cribari undertriage patients who were NFTI negative were now considered appropriate triage, as were Cribari overtriage who were NFTI positive. NFTI was basically used to do another level of screening on the outliers before resorting to individual chart review.

Once again, let’s look at over- and undertriage experience in the paper:

  • Undertriage: 9.1% undertriage (Cribari) reduced to 3.3% by adding STAT
  • Overtriage: 50% overtriage (Cribari) reduced to 31% by adding STAT

The authors concluded that adding STAT to the review process tightens up the numbers, reducing the number of charts that need to be reviewed individually. It also standardizes comparisons between hospitals that use STAT. This may be helpful for future triage-related research.

What Does It All Mean?

The Cribari grid has been around a long time, and people are both comfortable and facile using it. But it does tend to overestimate undertriage. In my experience, the raw Cribari undertriage rate is usually 12-22%. Individual chart analysis reduces this by about 10%. Overtriage rates are anywhere from 40% to 90%, and most centers do not review those charts because they don’t care much about reducing it.

Applying NFTI criteria to the over- and undertriage fallouts from Cribari makes sense. It appears to appropriately reduce both rates significantly. Undertriage remains the most significant factor to monitor. If you choose to adopt the use of the STAT technique, consider manually reviewing the undertriage charts that are being reclassified as appropriate for a few cycles. This should help confirm that STAT is really working for you.

One last thing. Using Cribari or NFTI or STAT does not absolve you of having good triage criteria for trauma activations. It is not possible to know a patient’s ISS or NFTI status as they are rolling through the door. The quality of your activation criteria are the first screen to try to ensure appropriate triage. If you keep finding undertriage events occurring, first look at your criteria. If those seem to be fine, then it’s time to scrutinize the people applying them!

Helpful Tools

The authors of the STAT paper provided some Excel spreadsheets to help add the Cribari matrix, NFTI, or STAT to your registry. Note that this only works for TraumaBase! If you use a different registry, contact your vendor for assistance.

The spreadsheets consist of three tabs/pages. On the first, enter the specific field names from your TraumaBase implementation. This fills in the code on the second tab which will be added to TraumaBase. The third tab gives explicit directions on how to add the feature to your registry.

Here are the downloadable file links provided by the authors:


  1. 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.
  2. Avoiding Cribari gridlock: The standardized triage assessment tool improves the accuracy of the Cribari matrix method in identifying potential overtriage and undertriage. J Trauma Acute Care Surg. 2018 May;84(5):718-726.
Print Friendly, PDF & Email

Undertriage And Overtriage: The Cribari Grid

Any trauma performance improvement professional understands the importance of undertriage and overtriage. Overtriage occurs when a patient who does not meet trauma activation criteria gets one anyway. And undertriage is the converse, where no activation is called despite criteria being met. As you may expect, the latter is much more dangerous for the patient.

I frequently get questions on the “Cribari Grid” or “Cribari Method” for calculating these numbers. Dr. Chris Cribari was a previous chair of the Verification Review Committee of the ACS Committee on Trauma. He developed a table-format grid that provides a simplified method for calculating these numbers.

But remember, the gold standard for calculating over- and undertriage is examining each admission to see if they actually met any of your trauma activation triage criteria. The Cribari method is designed for those programs that do not or cannot check these on every admission. And since most programs have too many trauma admissions to verify every single one, the grid technique can be very helpful. It is a surrogate for chart review that helps reduce the workload to identify patients with higher ISS that might have benefited from a trauma activation.

If you use the Cribari method, use it as a first pass to identify potential undertriage. In most trauma programs, the raw undertriage number using the grid will be around 10-20%. Obviously, this is unacceptably high. It requires the second pass: manually examining the chart of every patient in the undertriage list to see if they meet any of your activation criteria. If they did not, they would most likely not have been undertriaged. The second pass process usually decreases the undertriage rate by about 10%, usually reducing it below the acceptable threshold of 5%

But now you need to do a third pass. Look at each patient’s injuries and overall condition to ask yourself if they might have been better cared for by your entire trauma team. Even though they don’t meet any of your existing criteria, should they have? If so, you may need to add a new activation criterion. Then, count that patient as undertriage, of course.

I’ve simplified the Cribari Grid calculation process as much as possible and have provided a Microsoft Word document that automates the task. Just download the file, fill in the four highlighted values in the table, update the formulas using the instructions, and voila! You’ve got your numbers! Instructions for manual calculations are also included. Download it by clicking the image below or the link at the end of this post.

In my next post, I’ll examine how the NFTI score (Need For Trauma Intervention) fits into your undertriage calculations.

Click here to download the calculator.

Print Friendly, PDF & Email

Transfers In: Direct Admit vs Send To The ED

Level I and II trauma centers are frequently asked to accept patients who need a higher level of care. This necessitates an inter-hospital transfer that is subject to scrutiny by the trauma performance improvement program of both trauma centers. The practice at many centers is to bring all transfer patients in through the emergency department. But is this really necessary?

Bringing Patients To Your Emergency Department

  • Patients can be reassessed to see if they meet any of your trauma activation criteria.
  • The work-up from the referring hospital can be re-evaluated. If some testing or imaging has been omitted, it can be obtained after arrival.
  • Specialist assessment may be more timely or may involve interventions that are more difficult after leaving the ED. Here’s an example. In some hospitals, orthopedics may choose to place a traction pin to provide initial fracture management. They may choose to use sedation, which may not be as readily available on a surgery ward.
  • Access to certain critical services may be more rapid from the emergency department. A patient may be more rapidly taken to the operating room or interventional radiology if the patient is in the emergency department.
  • It is easier to determine the correct admitting service in the ED prior to the actual admission. Sometimes patients are suitable for admission to a surgical subspecialist service, or to a medical service if they have complex comorbidities. Initial admission to the correct service from the ED is easier than later transfer.

But there are a few downsides to ED arrival:

  • The emergency department may be swamped. Taking a patient who could just as easily have been admitted directly increases congestion in the ED and slows throughput even further.
  • There is a built-in time delay going through any emergency department. You can count on patients spending eight hours, if not much, much more if they come to the ED first.
  • It’s a big dissatisfier for patients. They’ve already gone through this time-intensive process once and are usually not happy to have to do it again.

Direct Admissions

Direct admissions essentially reverse the pros and cons listed for emergency department evaluation.

There is a mistaken belief that the ACS Verification Review Committee looks askance direct admissions. This is not the case, and there are no criterion deficiencies that refer to them. Direct admits may be reported on the site visit pre-review questionnaire, and the reviewers may have questions about your numbers and how you identify them. Otherwise, each center is free to choose how they handle them.

Here are some guidelines for directing incoming patients to the most appropriate place.

  • Are you familiar with the referring physician or APP? If you have worked with them before and are confident of their evaluation skills, then a direct admission could be appropriate.
  • Is the referring hospital a trauma center, and are you familiar with how they work up patients? What has your previous experience with them been? Again, if they are part of your hospital system and/or you have had successful direct admissions from them in the past, consider it again.
  • Will the patient need rapid access to specialized services after arrival? Do they need to go to the operating room quickly? Or might they need advanced imaging that can be arranged more expeditiously from the ED?
  • Will they need any procedures after arrival that are more easily done in your ED? Do they need a complicated laceration repair best done with equipment in the ED? Will they require conscious sedation for a procedure?
  • Are you unsure of the most appropriate admitting service? Does the patient have significant comorbidities? Do you have two or more potential admitting services but just need to lay eyes on the patient to help you decide?
  • How busy is your ED? The longer the wait time, the more desirable it is to just skip it altogether, especially if none of the items above apply.

But make sure that you are able to accurately identify and track each and every direct admission coming into the hospital. Although high numbers of direct admission patients is not a violation of ACS standards, allowing trauma patients to get into the hospital on non-trauma services without being identified by the PIPS program is. I recommend that you review each and every one of them shortly after they arrive. Then make sure the decision-making was correct and the patient is on the service that best meets their needs.

Print Friendly, PDF & Email