Category Archives: Performance Improvement

Autopsy Reports and Performance Improvement

December 9, 2025 The Trauma Pro Leave a comment

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.

How To “Track And Trend”

July 1, 2025 The Trauma Pro Leave a comment

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.

Performance Improvement

NFTI: A Nifty Tool To Replace The Cribari Grid?

May 13, 2025 The Trauma Pro Leave a comment

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 over a decade, but it 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. 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 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 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 believe 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: This is an elegant attempt to improve upon the simple (yet admittedly flawed) Cribari matrix method for assessment of major trauma patient triage. It was thoughtfully designed and evaluated at this one center. The authors recognize that it is based on retrospective data, but so is the Cribari technique.

I believe that NFTI can be used as an adjunct to Cribari. The matrix identifies gross under- and over-triage using ISS as a surrogate for trauma activation criteria. Normally, the trauma program then needs to review the outliers to see if mistriage actually occurred. It is basically a “first pass” that seeks to over-identify potential problem patients.

NFTI uses the need for resource utilization as a surrogate. I recommend that it be applied to the Cribari outliers, and then the remaining few charts can be analyzed to see if your trauma activation criteria were met. Combining both techniques can dramatically reduce the workload for reviewing undertriage cases.

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.

Performance Improvement

The Cribari Grid And Over/Undertriage

May 9, 2025 The Trauma Pro Leave a comment

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 than the former.

I frequently get questions on the “Cribari grid” or “Cribari method” for calculating these numbers. Dr. Chris Cribari is a former chair of the Verification Review Subcommittee 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 it met any of your trauma activation triage criteria. The Cribari method is designed for those programs that do not check these on every admission. It is a surrogate that allows you to identify patients with higher ISS who might have benefited from a trauma activation.

So, if you use the Cribari method, use it as a first pass to identify potential undertriage. Then, examine every patient’s chart in the undertriage list to see if they meet your activation criteria. If not, they were probably not undertriaged. However, you must then look at their injuries and overall condition to see if they might have been better cared for by your trauma team. If so, you may need to add a new activation criterion. Then, count that patient as undertriage, of course.

I’ve simplified the calculation process even more and provided a Microsoft Word document that automates the task for you. Just download the file, fill in four values in the table, update the formulas, and 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.

Download the calculator by clicking here

In my next post, I’ll examine how the NFTI score (need for trauma intervention) fits into the undertriage/overtriage calculations.

Performance Improvement, Philosophy

Don’t Write This In Your PI Committee Minutes!

May 6, 2025 The Trauma Pro Leave a comment

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!

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