Tag Archives: performance improvement

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 But it also contained a number of patients discussed yesterday who had support withdrawn due to age or degree of injury.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 The AMWOI category looks at whether there were any care issues, regardless of whether support was eventually withdrawn.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.

Related posts:

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.

Related posts:

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.

Related posts:

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.