Tag Archives: performance improvement

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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Trauma PI: Chasing Rumors

Trauma performance improvement (PI) is part art and part science. I tend to segregate the process into 3 segments: inputs, processing, and outputs. There are lots of possible inputs, including violation of specific audit filters (too long to OR, open fracture delay, etc.),  referrals from M&M discussions, incident reports and video reviews of trauma resuscitations, to name a few.

There is one PI input that has the potential to be a problem, though: word of mouth. You know, someone tells the trauma program manager that things just didn’t go well during that last trauma resuscitation. This is a perfectly legitimate way to identify PI issues. However, “word of mouth” can be categorized by source into “identified” and “anonymous." 

Word of mouth sources that are identified are not a problem. Anonymous ones are. All too often, these unsigned notes or suggestion box drops or phone messages are initiated by someone with an axe to grind. Most of the time, there is no basis for the incident that has been reported. The PI program can spend lots of time and energy trying to track down these perceived "problems”, and nothing ever comes of it.

There are two major problems with unsourced word of mouth “tips”:

  • There is no way to get additional information about the event from the source
  • It is not possible to thank the source for the information and let them know what was done to correct the issue

Bottom line: Performance improvement “tips” from anonymous sources are usually unfounded and a waste of time to investigate. Let it be known that your PI program is happy to receive written or verbal notices of potential problems that need to be pursued. However, every request must have a name and contact number and/or email included or it will be discarded.

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AAST 2011: Autopsy Reports and Performance Improvement

Autopsy reports have traditionally been used as part of the trauma performance improvement (PI) process. They are typically a tool to help determine preventability of death in 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 includes a question on what percentage of deaths at a trauma center undergo autopsy. Low numbers are usually discussed further, and strategies for improving them are considered. But are autopsies 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. 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 on 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 performance improvement standpoint, autopsy does 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. I would still recommend obtaining the reports for their educational value, especially for those of you who are part of training programs.

Reference: Dead men tell no tales: analysis of the utility of autopsy reports in trauma system performance improvement activities. AAST 2011 Annual Meeting, Paper 63.

Timed PI Audit Filters: When Does The Clock Start?

Several of the performance improvement (PI) audit filters typically used at trauma centers include a time parameter. These include:

  • Craniotomy > 4 hrs
  • Laparotomy > 4 hrs
  • OR for open fracture > 8 hrs
  • 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:

  • Arrival in the ED
  • When the diagnosis is made
  • 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 the ED. This enables the PI program to evaluate every system that can possibly enable or impede your patient’s progress to the OR.

Trauma PI: When Is A Peer Issue Really A System Issue? (Part IV)

Yesterday I discussed loop closure for system issues. Today I’ll look at the interesting relationship between peer and system issues.

Although most PI issues that arise seem to be related to something done (or not done) by an individual, that doesn’t mean that the issue is peer-related. Frequently a significant portion of the problem is caused by a system issue. How can this be?

Let’s take the example of DPL. A physician performs a DPL in the trauma bay and the trauma PI program notes that it was performed without the requisite placement of an NG tube and urinary catheter first. At first look, this is a peer-related problem, right? Just counsel the doctor and everything will be better.

Wrong! Your PI program needs to assume that every apparent peer-related problem is a manifestation of one or more system issues. In my example, another DPL is performed 6 months later by a different physician, and once again the catheters are not inserted first. What gives?

I recently wrote that DPL was a dying art. Most institutions perform this procedure only a few times a year. People get rusty with uncommon procedures because they can’t practice. So instead of considering this a physician problem, look at it as a system problem. How can you keep them from forgetting something they seldom do? Simple! Attach a gastric tube and a urinary catheter directly to the DPL kit. When the physician grabs the kit, they will be instantly reminded of the need to insert them first. Problem solved.

Bottom line: always assume that people are doing their best to provide excellent care to their patients. Look closely for possible system problems that are keeping them from doing just that. Then put your thinking cap on and come up with some creative solutions.

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