Tag Archives: PI

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Trauma Overtriage: Why Is It Bad?

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Back in December I talked about the dangers of undertriaging trauma patients (click here to review). What about the opposite problem, overtriage?

First, how do you calculate your overtriage rate? It’s pretty simple. Use your trauma registry to count how many patients arriving in the ED were trauma activations but didn’t meet any criteria:

(Number of ED trauma patients who were trauma activations
                         but did not meet activation criteria)

        ——————————————————–           x 100
                  (Total number of trauma activations)

This can only be accurately determined if the activation criteria are recorded on each patient. If not, use the following equation:

 (Number of ED trauma patients who were trauma activations
                                     with ISS <= 15)
       ———————————————————           x 100
                  (Total number of trauma activations)

Values can range from 0% to 100%. The usually acceptable overtriage rate is 50-80%. What happens when the overtriage rate is too high? You wear out your trauma team. They are being called for patients with injuries that don’t warrant it.

The solution for overtriage? Change your activation criteria, or add a second level trauma response that doesn’t require as many people to respond. This requires a thoughtful analysis of your existing criteria so you can decide what needs to be changed or discarded.

The danger? More undertriage. Over- and undertriage go hand in hand. As overtriage decreases, undertriage increases. You need to strike a balance so that the undertriage rate stays below 5%. This makes an excellent performance improvement (PI) program project!

General

Trauma Undertriage: Why Is It Bad?

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Trauma centers look at over- and undertriage rates as part of their performance improvement programs. Both are undesirable for a number of reasons. I’ll focus on undertriage today, why it happens and what can be done about it.

Undertriage in trauma care refers to the situation where a patient who meets criteria for a trauma activation does not get one. First, calculate your “magic number”, the number of patients who should have been trauma activations.

If you track the exact triage criteria met at your hospital, it is calculated as follows:

 Magic Number = (Number of ED trauma patients who met activation criteria
                                           but were not trauma activations)

If you don’t track the triage criteria, you can use ISS>15 as a surrogate to identify those patients who had severe enough injuries that should have triggered an activation. This is not as accurate, because you can’t know the ISS when the patient comes in, but it will do in a pinch. In that case, the magic number is:

Magic Number = (Number of ED trauma patients with ISS>15
                                           but were not trauma activations)

Your undertriage rate is then calculated as follows

                                        Magic Number
        ———————————————————–    x 100
                   Total number of trauma patients seen in ED

Undertriage is bad because patients who have serious injuries are not met by the full trauma team, and would benefit from the extra manpower and speed possible with an activation.

The most common causes for undertriage are:

  • Failure to apply activation criteria
  • Criteria are too numerous or confusing
  • Injuries or mechanism information is missed or underappreciated

Undertriage rates can range from 0% to infinity (if you never activate your trauma team). A general rule is to try to keep it below 5%.

If your overtriage rate is climbing past the 5% threshold, identify every patient who meets the ISS criterion and do a complete ED flow review as concurrently as possible. Look at their injuries/mechanism and your criteria. If the criteria are not on your activation list, consider adding them. If the criterion is there, then look at the process by which the activation gets called. Typically the ED physicians and nurses will be able to clarify the problem and help you get it solved. 

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Performance Improvement for FAST

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FAST is an integral component of major trauma evaluation. Unfortunately, although lots of people do them, quality control is not very consistent.

Researchers at the University of Pennsylvania studied how the use of a standard checklist and it’s impact on exam quality. Detection of fluid in any of the standard 4 FAST locations was recorded for every exam performed. No attempts were made to grade the amount of fluid seen. The exam was recorded in video format. 

Reviewers credentialed in FAST later reviewed the study videos in a blinded fashion using a checklist. They were also not aware of any CT or OR findings. The checklist contained grading for quality (poor, fair, good), result (positive, negative, unclear), and initial interpretation (positive, negative) for each of the 4 areas scanned. The study was also graded for its educational value. 

A total of 247 studies were reviewed. All study results were compared with CT (240) or OR (7) results. There 235 true negatives, 6 true positives, 4 false positives and 2 false negatives. Sensitivity was 75%, specificity was 98%, and accuracy was 98%.

Overall, 9% of exams were of good quality, 65% were fair, and 26% were poor. Despite this lack of good quality exams, sensitivity, specificity and accuracy adhered to the usual literature standards. The overall quality in both true and false exams were similar. 

Bottom line: This study reveals that we are doing an “okay” job with FAST exams in trauma patients. However, it also shows that there is room for improvement, and that FAST evaluation should be a part of the Performance Improvement program of any trauma centers that use FAST.

Reference: Performance Improvement for FAST Exam. University of Pennsylvania. Presented at the Eastern Association for the Surgery of Trauma meeting, Poster #24, January 2010.