Category Archives: Performance Improvement

The Cribari Grid And Over/Undertriage

I’ve spent some time discussing undertriage and overtriage. I frequently get questions on the “Cribari grid” or “Cribari method” for calculating these numbers. Dr. Cribari is a previous 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 they 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 that 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 the chart of every patient in the undertriage list to see if they meet any of 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, perhaps you need to add a new activation criterion. And 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 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.

cribarigrid

Download the calculator by clicking here

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Timed PI Audit Filters: When Does The Clock Start?

This is a question that comes up frequently in trauma performance improvement programs. Several of the performance improvement (PI) audit filters typically used at trauma centers include a time parameter. Some of these include:

  • Craniotomy > 4 hrs
  • Laparotomy > 4 hrs
  • OR for open fracture > 8 hrs (although this is now outdated)
  • OR for compartment syndrome > 2 hrs

The question that needs to be asked is: 2 or 4 or 8 hours after what?

There are several possible points at which to start the clock:

  • Time of the scene of the traumatic event
  • Recognition at an outside hospital (for referred patients)
  • Arrival in your  ED
  • When the diagnosis is made in your ED
  • When the decision to operate occurs

The answer is certainly open to interpretation. 

Here is my opinion on it:

The purpose of a PI filter is to measure system performance. There are a myriad of system problems that can delay taking a patient to the OR. These include care delays in the ED, delays in getting or interpreting diagnostic tests, delays in contact or response for consultants, delays in diagnosis, delays in OR scheduling or availability, and more. Does it make sense to limit the evaluation of your system by setting one of the later decision points as your start time?

Bottom line: I recommend starting the audit filter clock at the time of patient arrival in your ED. This enables the PI program to evaluate every system in your hospital that can possibly enable or impede your patient’s progress to the OR. However, if the issue was recognized at an outside hospital, scrutiny of their processes also needs to occur. Their trauma PI coordinator needs to know so they can make sure the transfer to definitive care occurred as quickly as possible. 

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Trauma Mortality: The New Nomenclature – Part 3

Time to finish up this series on trauma mortality! We discussed the two types of anticipated mortality last week, now it’s time for the final (and worst) one.

Old nomenclature: preventable death
New nomenclature: unanticipated mortality

Note the subtle difference. The old name presumes you could have done something about it, which can lead to legal issues in some cases. The new one implies that death was unexpected, but does not presume that it could have been prevented. A good example would be a trauma patient who suddenly dies from a massive PE, despite DVT prophylaxis done according to the book.

Any unanticipated mortality should launch a full investigation from the trauma performance improvement program. In some cases, hospital PI may get involved. A root cause analysis may be indicated, depending on how many factors are involved. These cases must be discussed by the multidisciplinary trauma PI committee. It’s essential that everyone involved do their homework and become familiar with every aspect of care so that a meaningful analysis can occur at the meeting.

Trauma center reviewers will expect to see detailed documentation of the analysis in the PI committee minutes. And unless the death was a complete and nonpreventable surprise there should be new protocols, policies and practice changes apparent. If these are not present, expect major reverification issues for your trauma center.

Is there an appropriate ratio of the three types of mortality? Obviously, there is a fair amount of variability. But after years of doing reviews, I can offer some guidelines. Here’s my 100:10:1 rule of thumb:

  • 100 cases – Anticipated mortality without opportunity for improvement (AMW/OOI)
  • 10 cases – Anticipated mortality with opportunity for improvement (AMWOI)
  • 0-1 case – Unanticipated mortality (UM)

If your hospital’s numbers are outliers in any group, your clinical care and performance improvement program will get extra scrutiny. If all your cases are AMW/OOI, then your PI process is too lax. This is a complex business, and there a many ways to improve our care. If your AMWOI cases are more frequent, your threshold for improvement may be set too low (see my post on this last week). If you have more than 1 or 2 UM, then there may be some serious care quality issues.

Bottom line: When reviewing trauma mortality, be realistic but brutally honest. We learn from the mistakes we make. But by adhering to the process, you should never make the same mistake twice.

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Trauma Mortality: The New Nomenclature – Part 2

Yesterday I tried to clarify the most commonly assigned type of trauma mortality, anticipated mortality without opportunity for improvement (AMW/OOI). Today, I’ll cover another, and I’ll finish the series on Monday.

Old nomenclature: potentially preventable death
New nomenclature: anticipated mortality with opportunity for improvement (AMWOI)

Again, these sound somewhat similar but they are quite different. Potentially preventable death used to be applied to patients who had obvious care issues that had some potential to change outcome. But it also contained a number of patients discussed yesterday who had support withdrawn due to age or degree of injury. There was some nagging doubt that, it something else had been done, maybe they would have recovered. So several of the “potentially preventable” deaths in the old category have been moved to the “without opportunity for improvement” category.

Unfortunately, a larger group of patients from the nonpreventable death category have moved into the “with opportunity for improvement” category. This is actually a good thing, though. The AMWOI category looks at whether there were any care issues, regardless of whether support was eventually withdrawn.

Whereas the vast majority of deaths at any center should fall into the AMW/OOI category, a modest number will be classified as AMWOI. The actual number depends on how broadly or narrowly an opportunity for improvement is defined. If you consider a few areas of missing documentation on the trauma flow sheet an opportunity for improvement, then you’ll have a lot of deaths classified this way. Concentrate on issues that might have actually had an impact on the outcome. The key is to develop a set of criteria that is realistic and that work for you. If the number of AMWOI deaths seems high, go back and look at those criteria and adjust them. You can still work out a system for improving trauma flow documentation without it changing every death in a trauma activation to one with an opportunity for improvement.

Monday, I’ll finish up with a few words on unanticipated mortality.

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Trauma Mortality: The New Nomenclature

The American College of Surgeons adopted a new naming convention for trauma deaths last year. Of course, anytime you change something up, there will be some confusion. I’m going to compare old and new and give some of my thoughts on the nuances of the changes.

Old nomenclature: Nonpreventable death
New nomenclature: Anticipated mortality without opportunity for improvement (AMW/OOI)

They seem similar, right? But the new name takes into account a growing phenomenon: elderly patients (or younger ones for that matter) who sustain injuries that might be survivable, but are devastating enough to cause the family to withdraw support. Technically, the deaths could be preventable to some degree, but the family did not wish to attempt it. The new system recognizes that it is an expected outcome due to patient or family choice.

There are several key points to handling AMW/OOI. First, if your center is providing great care, the majority of your deaths should be classified this way. Every one of them needs some degree of review, whether from just the trauma medical director and/or program manager or via the full trauma PI committee. However, your full PI committee needs to at least see a summary of the death if it’s not discussed in full.

How to decide on abbreviated review and report vs discussion by full committee? It depends on your trauma volume, and program preference. Higher volume centers do not usually have the luxury of discussing every case due to time constraints.

Tomorrow I’ll discuss the next type of trauma mortality, aniticipated mortality with opportunity for improvement, and I’ll finish the series on Monday.

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