The theory of trauma performance improvement is relatively straightforward. Mastering the art of trauma PI can be much more challenging.
Three trauma experts shared practical ideas for leading successful PI projects during a session at the 2016 Annual Conference of the Trauma Center Association of America. They discussed effective strategies for identifying PI cases, performing loop closure and working with others to achieve system-wide improvements.
Using the triage grid to identify multiple PI issues
Chris Cribari, MD, FACS, medical director for acute care surgery at the Medical Center of the Rockies in Loveland, Colorado, looked at trauma performance improvement from both a historical and practical point of view. He began by reviewing the evolution of trauma PI and later discussed how triage analysis can help identify several PI opportunities.
“Many people are familiar with the grid method of evaluating trauma triage,” Dr. Cribari said during a separate interview. “It’s one simple method for identifying potential instances of overtriage and undertriage that then require further case review. But one important thing for people to keep in mind is that the case review often uncovers additional opportunities for performance improvement other than just the triage decision.”
For example, a grid analysis might identify a potential case of undertriage. “Later, when you review the chart, you might see that the patient did in fact meet higher triage criteria,” Dr. Cribari said. “However, the chart review might reveal another problem, such as a prolonged scene time, a piecemeal evaluation in the emergency center or failure to identify that the patient was anticoagulated. All these findings can be opportunities for improvement where an action plan could be put in place.”
Choosing the right level of case review and loop closure
Janet Cortez, MS, RN, trauma program manager at University of Utah Health Care in Salt Lake City, discussed guidelines for conducting case review according to the Trauma Outcomes and Performance Improvement Course (TOPIC) developed by the Society of Trauma Nurses.
“There are different methods of reviewing cases,” Cortez said in an interview. “You might conduct a primary, a secondary or a tertiary review, depending on the complexity of the issue. Generally speaking, the more complex the issue, the more thorough you have to be to resolve it.”
Cortez also discussed effective loop closure methodologies. “One key is to make sure that your loop closure activities are clearly defined and documented.”
According to Cortez, loop closure methods should match the level of review. “You don’t have to do a tertiary loop closure for every single issue,” she said. “Loop closure can occur at any level, depending on the issue at hand. It could be done with a tertiary review, but it could also be done with just a primary review.”
Collaborating system-wide to improve performance
Tim Murphy, MSN, RN, trauma performance improvement coordinator at Robert Wood Johnson University Hospital in New Brunswick, New Jersey, shared strategies for working with pre-hospital providers to improve system performance. He described a recent hospital PI issue that grew into a statewide initiative in New Jersey focused on spine immobilization.
“At the start of this year, our pre-hospital providers launched an effort aimed at getting more in alignment with national trends to reduce backboard use,” Murphy said in an interview. “The trauma community had reservations, because we started to see many injured patients with a trauma activation coming in without cervical collars or any spine precautions. Some people came in sitting up. We were finding a lot of spine fractures for these patients.”
“Our trauma PI program met with EMS leadership to address concerns,” Murphy said. State trauma leaders then launched a system-wide PI effort to update EMS practice regarding immobilization. “If you look at the national standards, patients who warrant activation still warrant immobilization.”
One key to effective system PI is ongoing follow-up. “We closed the loop with our local EMS folks and then extended those efforts statewide,” Murphy said. “But there is always backsliding, even with your local efforts. So closing the loop is a continual effort on all our parts.”
He stresses the importance of communication. “This effort was a bit of a challenge at first, because at that time our statewide trauma committee was still in the formative stage,” Murphy said. “Now we have a stronger infrastructure to help ensure communication between all parties and make sure everyone is on the same sheet of music. It all goes back to communication, because trauma is a team sport.”