Category Archives: Performance Improvement

When Does The PI Clock Start Ticking?

December 8, 2017 The Trauma Pro Leave a comment

This is a question that comes up frequently in trauma performance improvement (PI) programs. Several of the 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 8 hrs (although this is now outdated)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?

Let’s consider the following scenario:

A young male is involved in a motor vehicle crash and strikes his head. He enters your trauma center at exactly midnight as a trauma activation. Head CT shows a 12mm epidural hematoma with 8mm midline shift and ventricular effacement. GCS was 14 on arrival, but has declined to 12 by the time you leave the CT scanner. He is taken to the OR for craniotomy by neurosurgery at 4:15.

And this one:

A young male is involved in a motor vehicle crash and strikes his head. He enters your trauma center at exactly midnight as a trauma activation. Head CT shows a 7mm epidural hematoma with no shift and no effacement. GCS is 15, and the neurologic exam is completely normal. He is admitted to the SICU for neuro monitoring and is scheduled to have a repeat CT scan at 06:00. The scan shows significant expansion of the hematoma, with midline shift and ventricular effacement. He is taken to the OR for craniotomy by neurosurgery at 6:55.

My questions for you:

When does the PI clock start ticking in each case?
What information do you need to review to make this decision?
Do you send a PI “love note” to the neurosurgeons in either case?

Share your thoughts on Twitter or by commenting below. I give you my answers in the next post.

When Is It Not An “Unplanned ICU Admission?”

July 24, 2017 The Trauma Pro Leave a comment

All US trauma centers verified by the American College of Surgeons (ACS) must now subscribe to the ACS Trauma Quality Improvement Program (TQIP). This program allows each center to benchmark themselves against other trauma centers that are just like them (level, volume, acuity, etc). Every quarter, TQIP members receive a report that details their performance in a number of key categories. The report slices and dices a large number of data points, and shows how they compare to those other trauma centers.

One of the more interesting portions of the TQIP report deals with risk-adjusted complications. The one I wrote about yesterday, the “ICU bounce back,” is officially called an “unplanned ICU admission.”

I’ve had several trauma centers ask me what constitutes an unplanned ICU admission. Is it any bounce back? What about patients who were never in the ICU?

This questions is particularly important to me because my own center’s TQIP report shows that we have a significant number of unplanned ICU admissions. But I know for a fact that they are not surprises. We have an inpatient trauma unit, with capabilities somewhere between the usual ward bed and an ICU bed. Patients can get telemetry, continuous oximetry, vital signs every 2 hours, and more. It functions as a kind of step-down unit, so we frequently admit patients who may require ICU admission at other hospitals.

Every once in a while, a patient who is receiving care in the trauma unit shows signs that they are going to need a true ICU level of care. In that case, we promptly move them to the ICU before they decompensate any further.

Is that situation an “unplanned ICU admission?” In my opinion, no. The patient received the highest level of care while outside the ICU, and ultimately a considered decision was made to move them. In my mind, this is a “planned ICU admission.”

Bottom line: There are two issues at play if your “unplanned ICU admissions” get flagged on your TQIP report. The first is determining if it was truly unplanned. If the Rapid Response Team (RRT) was called, then it was almost certainly unplanned. But if the patient was being monitored properly, showed signs that they would need an ICU level of care, and was preemptively transferred there, it was not. Similarly, if one of your surgical specialists wants the patient transferred (e.g. MAP goals), then that is also a planned admission.

The second factor is figuring out why the admissions are getting reported to TQIP as unplanned. This is usually a trauma registrar issue. They may be looking for any ward to ICU transfer, and classifying it as unplanned. Educate all your registrars on the nuances of what is planned and what isn’t.

If you are on the receiving end of a TQIP variance on unplanned ICU admissions, use the drill-down tool to identify the exact patient records involved. Review the involved medical records, paying close attention to vital signs, monitoring, and all decision making leading up to the time of the ICU transfer. If it isn’t truly unplanned, educate your registrars. But if it is, make sure that it was properly dealt with by your trauma performance improvement program.

Performance Improvement

Does The Tertiary Survey Really Work?

June 21, 2017 The Trauma Pro Leave a comment

Delayed diagnoses / missed injuries are with us to stay. The typical trauma activation is a fast-paced process, with lots of things going on at once. Trauma professionals are very good about doing a thorough exam and selecting pertinent diagnostic tests to seek out the obvious and not so obvious injuries.

But we will always miss a few. The incidence varies from 1% to about 40%, depending on who your read. Most of the time, they are subtle and have little clinical impact. But some are not so subtle, and some of the rare ones can be life-threatening.

The trauma tertiary survey has been around for at least 30 years, and is executed a little differently everywhere you go. But the concept is the same. Do another exam and check all the diagnostic tests after 24 to 48 hours to make sure you are not missing the obvious.

Does it actually work? There have been a few studies over the years that have tried to find the answer. A paper was published that used meta-analysis to figure this out. The authors defined two types of missed injury:

Type I – an injury that was missed during the initial evaluation but was detected by the tertiary survey.
Type II – an injury missed by both the initial exam and the tertiary survey

Here are the factoids:

Only 10 observational studies were identified, and only 3 were suitable for meta-analysis
The average Type I missed injury rate was 4.3%. The number tended to be lower in large studies and higher in small studies.
Only 1 study looked at the Type II missed injury rate – 1.5%
Three studies looked at the change in missed injury rates before and after implementation of a tertiary survey process. Type I increased from 3% to 7%, and Type II decreased from 2.4% to 1.5%, both highly significant.
10% to 30% of missed injuries were significant enough to require operative management

Bottom line: In the complex dance of a trauma activation, injuries will be missed. The good news is that the tertiary survey does work at picking up many, but not all, of the “occult” injuries. And with proper attention to your patient, nearly all will be found by the time of discharge. Develop your process, adopt a form, and crush missed injuries!

Related posts:

Reference: The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scand J Trauma Resusc Emerg Med 20:77, 2012.

Performance Improvement

Dealing With Trauma Flow Sheet Documentation Problems

February 9, 2017 The Trauma Pro Leave a comment

Over the years, I’ve commented a number of times on paper vs electronic trauma flow sheet. For those of you who somehow missed it, let me recap. Don’t use an electronic trauma flow sheet yet if you can possibly avoid it!

I look at the flow sheet as having two phases, input and output. The input phase occurs as data is being recorded on the sheet, hopefully in real time as events occur during the trauma resuscitation and its aftermath. The output phase consists of a human reviewing the completed flow sheet and analyzing the events and timing for performance improvement (PI) purposes.

The electronic trauma flow sheet has major problems in both phases. But the good, old-fashioned paper sheet isn’t perfect either. It is subject to problems during the input phase. The most common issue is incomplete documentation. I’ve seen so many trauma programs with ongoing issues in this area, and they struggle to find ways to improve or eliminate the missing data.

Here are a few tips you should consider:

Make sure your paper flow sheet is well-designed. Data items should not be scattered randomly over several pages. Primary survey items should be grouped together. Medications must have their own block. Diagnostic tests performed (not ordered) should be in the same area. Make sure that the narrative block that typically has vital signs and free-form text about what is happening is large enough, with enough room to write comfortably. There are so many good trauma flow sheets out there already. Borrow a few to see if your program can adopt some of the organizational concepts found on them.
Identify the commonly incomplete items at your program, then redesign the flow sheet to cluster them together in one prominent spot on it. Common missed items include patient temperature, time of diagnostic tests, and admitting destination and time the patient leaves the emergency department.
If you have only a few problem data points and don’t want to totally redesign your form, manually highlight those blocks with an old-fashioned highlighting pen. This only works if you are highlighting a few items. Any more than two or three, and the scribe will start to ignore all of them. The fancy colored blocks will draw the eye and remind them to ask for the data.
Perform an accuracy review of the sheet soon after the resuscitation, ideally before the end of the nursing shift. And since the scribes are typically emergency nurses, it should be their responsibility. Not the trauma program’s. The ED nurses should take responsibility for their own work, and develop their own program to self-correct any deficiencies.

Do you have any suggestions or best practices that have worked for you? Please comment or tweet!

Related posts:

Performance Improvement

Value Of The “Delay To Operating Room” Trauma PI Filter: Part 2

February 2, 2017 The Trauma Pro Leave a comment

Yesterday, I discussed a paper that tried to show that the “delay to OR” trauma performance improvement (PI) filter was not cost effective. As I mentioned, I’m dubious that the outcomes and information reviewed could realistically demonstrate this.

Today, I’m going to list the parts of the system that this PI filter helps to monitor:

Was the patient appropriately triaged as a trauma activation?
Was the trauma surgeon called / involved in a timely manner?
Was an appropriate physical exam carried out?
If needed, was the CT scanner accessible?
Did the surgeon make an appropriate clinical decision?
If needed, did the backup trauma surgeon arrive in a timely manner?
Were there any transport delays to the OR?
Was an OR room promptly available?
Did the OR backup team arrive within the required time, if needed?
Were anesthesia services promptly available?
If a failure of nonoperative management occurred:
- Was the practice guideline followed?
- Were repeat vitals and physical exam performed and documented?
- Did any of the other issues listed above occur?

And you may be able to think of even more!

Bottom line: As you can see, this seemingly innocuous filter tests many components within the trauma center. And even if one particular patient who triggers the “delay to OR” filter is lucky enough to escape unharmed, many of the areas listed above can harm other patients who may not trigger it. Actively looking for these issues and fixing them makes your entire trauma program better!

Related post:

“Delay to OR” filter: Part 1

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