Tag Archives: performance improvement

Blame The Trauma Surgeon?

I found an interesting paper published a couple of years ago that purports to examine individual surgeon outcomes after trauma laparotomy. This was presented at the annual AAST meeting in 2021 and then published in the Journal the following year.

Everyone seems to be giving this paper a pass. I won’t be so easy on it. Let me provide some details.

The authors observe that the mortality in patients presenting in shock who require emergent laparotomy averages more than 40%, and hasn’t changed significantly in at least 20 years. They also note that this mortality varies widely from 11-46%, and therefore, “significant differences must exist at the level of the individual surgeon.” They go on to point out that damage control usage varies between individuals and trauma centers, which could lead to the same conclusion.

So the authors designed a retrospective cohort study of results from their hospital to try to look at the impact of individual surgeon performance on survival.

Here are the factoids:

  • Over the 15-month study period, there were over 7,000 trauma activations and 252 emergent laparotomies for hemorrhage control
  • There were 13 different trauma surgeons, and the number of laparotomies for each ranged from 7 to 31, with a median of 15
  • There were no differences in [crude, in my opinion] patient demographics, hemodynamics, or lab values preop
  • “Significant” differences in management and outcomes between surgeons were noted:
    • Median total OR time was significantly different, ranging from 120-197 minutes
    • Median operation time was also different, from 75-151 minutes across the cohort of surgeons
    • Some of the surgeons had a higher proportion of patients with ED LOS < 60 minutes and OR time < 120 minutes
    • Resuscitation with red cells and plasma varied “significantly” across the surgeons
  • Mortality rates “varied significantly” across surgeons at all time points (24-hour, and hospital stay)
  • There were no mortality differences based on surgeons’ volume of cases, age, or experience level

The authors acknowledged several limitations, included the study’s retrospective and single-center nature, the limited number of patients, and its limited scope. Yet despite this, they concluded that the study “suggests that differences between individual surgeons appear to affect patient care.” They urge surgeons to openly and honestly evaluated ourselves. And of course, they recommend a large, prospective, multicenter study to further develop this idea.

Bottom line: This study is an example of a good idea gone astray. Although the authors tried to find a way to stratify patient injury (using ISS and individual AIS scores and presence of specific injuries) and intervention times (time in ED, time to OR, time in OR, op time), these variables just don’t cut it. They are just too crude. The ability to meaningfully compare these number across surgeons is also severely limited by low patient numbers. 

The authors found some fancy statistical ways to demonstrate a significant difference. But upon closer inspection, many of these differences are not meaningful clinically. Here are some examples:

  • Intraoperative FFP ranged from 0-7 units between surgeons, with a p value of 0.03
  • Postoperative FFP ranged from 0-7 units, with a p value of 0.01
  • Intraoperative RBC usage was 0-6 units with the exception of one surgeon who used 15 in a case, resulting in a p value of 0.04

The claim that mortality rates varied significantly is difficult to understand. Overall p values were > 0.05, but they singled out one surgeon who had a significant difference from the rest in 22 of 25 mortality parameters listed. This surgeon also had the second highest patient volume, at 25.

The authors are claiming that they are able to detect significant variations in surgeon performance which impacts timing, resuscitation, and mortality. I don’t buy it! They believe that they are able to accurately standardize these patients using simple demographic and performance variables. Unfortunately, the variables selected are far too crude to accurately describe what is wrong inside the patient and what the surgeon will have to do to fix it.

Think about your last 10 trauma laparotomies where your patient was truly bleeding to death. How similar were they? Is there no difference between a patient with a mesenteric laceration with bleeding, an injury near the confluence of the superior mesenteric vessels, and a right hepatic vein injury? Of course there is. And this will definitely affect the parameters measured here and crude outcomes. Then add some unfavorable patient variables like obesity or previous laparotomy.

In my estimation, this paper completely misses the point because it’s not possible to retrospectively categorize all the possible variables impacting “surgeon performance.” This is particularly true of the patient variables that could not possibly be captured. The only way to do this right is to analyze each case as prospectively as possible, as close to the time of the procedure and as honestly as possible. And this is exactly what a good trauma M&M process does!

So forget the strained attempts at achieving statistical significance. Individual surgeon performance and variability will come to light at a proper morbidity and mortality conference, and should be evened out using the peer review and mentoring process. It’s not time to start blaming the surgeon!

Reference: It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy. J Trauma 92(5):769-780, 2022.

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.

  Pros:

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

  Cons:

  • 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.

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.

Best Of AAST 2021: Reducing Errors In Trauma Care

Finally, a performance improvement (PI) abstract at AAST!

As many of you know, there are two general types of issues that are encountered in the usual PI processes: provider (peer) vs system. Provider issues are errors of omission or commission by an individual clinician. Examples include a surgeon making a technical error during a procedure, or prescribing the wrong drug or dose for some condition.

One might think that provider issues are the most common type of problem encountered. But they would be wrong. The vast majority of clinicians go to work each day with the idea that they will do their job to the best of their abilities. So how could things go awry?

Because the majority of errors have some degree of system component! They are set up to fail by factors outside their perception and/or control. Let’s look at a surgeon who has several small bowel anastomoses fall apart. His surgery department head chides/educates him, reports him to hospital quality, and proctors his next ten bowel cases. Everything is good, right?

But then, two months later, the stapler company issues a recall because they found a higher than usual number of anastomotic failures with one of their products. So it wasn’t the surgeon after all, like everyone assumed. This is an extreme example, but you get the idea. System issues often look like peer issues, but it’s frequently difficult for many PI programs to recognize or accept this.

A multi-institutional group reviewed the results of a newly implemented Mortality Reporting System (MRS) to analyze a large number of PI opportunities for improvement (OFI). More than 300 trauma centers submitted data to the MRS when a death occurred where an OFI was identified. The reports included details of the incident and mitigation strategies that were applied.

 

Here are the factoids:

  • A total of 395 deaths were reviewed over a two year period
  • One third of deaths were unanticipated (!!), and a third of those were failure to rescue
  • Half of errors pertained to clinical management, clinical performance, and communication
  • Human failures occurred in about two thirds of cases
  • The most common remedy applied was education, which presumes a “provider issue”
  • System strategies like automation, standardization, and fail-safe approaches were seldom used, implying that system issues were seldom recognized
  • in 7%, the trauma centers could not identify a specific strategy to prevent future harm (!!!)

The authors concluded that most strategies to reduce errors focus on individual performance and do not recognize the value of system-level intervention.

Bottom line: Look at the pyramid chart above (interesting choice for a chart, but very effective). The arrow shows progression from provider focus to systems focus. The pyramid shows how the recognition of and intervention for system issues drops off very rapidly.

I am both shocked and fascinated by the last bullet point. A strategy couldn’t be developed to prevent the same thing from happening again. Now, there are a few rare instances where this could be correct. Your patient could have been struck by a bolt of lightning in her room, or a meteorite could have crashed through the wall. But I doubt it. This 7% illustrates the importance of investigating all the angles to try to determine how the system failed!

For once, I have no critique for an abstract. It is a straightforward descriptive study that reveals an issue that many in PI are not fully aware of. I’ll definitely be listening to this one, and I really look forward to the published paper!

Reference: ERROR REDUCTION IN TRAUMA CARE: LESSONS FROM AN ANONYMIZED, NATIONAL, MULTI-CENTER MORTALITY REPORTING SYSTEM. AAST 2021, Oral abstract #17.

Coming Soon! New Site For Trauma PI!

One of the most common requests I get is to provide more detailed content on Trauma Performance Improvement! To that end I am putting together a collection of print and video content on a new website that will address the things you really want to hear about but can’t find anywhere else.

Here’s a sample listing of some of the topics that will be covered:

  • Writing a good PI plan
  • Loop closure – basic to advanced
  • Involving your TMD
  • PRQ preparation
  • Creating workable practice guidelines
  • Crafting a Massive Transfusion Protocol that works for you
  • How to calculate your optimal number of trauma registrars
  • Preparing for your site survey
  • How to read your TQIP report
  • What is OPPE and how do I do it?
  • Integrating PI with your registry
  • How to interpret the Orange Book

If you want to be one of the first to get access to this content, please fill out the form by clicking here. Your name will be placed on my early bird e-mail list. I’ll provide regular updates on the opening date, and solicit your ideas on specific content you would like to see.

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