A core strategy of trauma performance improvement (PI) is reducing unnecessary variation in care. The key, according to the Orange Book, is to implement clinical practice guidelines and algorithms derived from evidence-based resources. This is a major opportunity in trauma PI — but also a major challenge.

“Trauma teams that consistently deliver evidence-based care achieve better patient outcomes, but keeping the guidelines top of mind is an ongoing challenge,” said Timothy Ryken, MD, MS, chief of neurosurgery at Dartmouth-Hitchcock. “Especially in the high-stress critical care environment, it is very difficult to make evidence-based decisions 100% of the time.”

Dr. Ryken is a member of the advisory board of Qmetis, a healthcare technology company that helps hospitals achieve the highest possible levels of quality. Qmetis has developed a decision support tool that provides physicians and nurses with instant bedside guidance on evidence-based standards.

• The Qmetis system includes an Adult TBI module based on the recently updated Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition.
• It also has a Pediatric TBI module that incorporates the current guidelines for infants, children and adolescents.

Physicians and nurses say the Qmetis system is an easy-to-use tool that helps them make sure they do not miss any opportunities to provide the best care.

“We have found that many physicians and nurses are delivering evidence-based care in the ICU only 60% of the time,” Dr. Ryken said. “For anyone responsible for performance improvement, this is a big opportunity.”

Decision support tools like Qmetis can help trauma PI committees achieve five important goals:

1. Ensure trauma patients receive evidence-based care

The Orange Book requires trauma programs to use evidence-based guidelines and protocols (CD 16-4). The challenge is that clinical guidelines are complex and can change frequently. Qmetis solves this problem with an intuitive interface that provides the relevant guidelines exactly when they are needed.

When a trauma patient is admitted to the ICU, a physician or nurse uses a tablet computer to answer a short series of questions. The entire enrollment process takes about two minutes.

The Qmetis system then generates an instant report showing precisely where the patient’s care varies from current guidelines. It also cites the source and level of the recommendation.

“The system flags things that are well understood but often missed,” Dr. Ryken said. “For example, even though it is recommended that patients be up to full nutrition within 5 to 7 days, sometime patients aren’t even started on feedings for 3 to 4 days post-injury.”

“Other recommendations cover treatments like cerebrospinal fluid drainage,” he said. “It’s ultimately the surgeon’s judgment, but the system helps make sure your decision takes the best guidelines into account.”

Guideline adherence may help reduce the need for long-term care. In a study at Wayne State University and Detroit Medical Center, TBI patients managed according to guidelines for mean arterial pressure, intracranial pressure and PaCO2 were more likely to have an improving GOS score at 6-month follow-up.

2. Identify relevant PI events

The Orange Book also requires trauma programs to implement mechanisms for identifying PI events. It specifies “pathway and protocol variance” as one effective method.

The Qmetis system supports event identification in two ways:

• When program leaders receive anecdotal reports of poor quality care for a specific patient, PI staff can use the system to review actual care against care guidelines. As a supplement to chart review, the system can zero in on recommended interventions that might have been missed.
• Program leaders can also use the system to run reports on specific protocols. For example, a report might show that compliance with DVT prophylaxis recommendations is only 65%. Significant variance from current guidelines would make this issue a potential candidate for PI committee attention.

As an event identification tool, the system is valuable because it can flag quality problems before they lead to patient harm.

3. Drill down to the right corrective action

Programs like TQIP indicate where patient outcomes are worse than expected. But once you identify lower-than-expected outcomes, you still need to pinpoint the cause.

“Clinical teams often look at poor outcomes and say, ‘We have to do better at compliance.’ But it’s not clear where to start,” Dr. Ryken said. “One benefit of this system is that it breaks head injury management down to 20 main points.”

For example, a trauma program is struggling with severe TBI outcomes. A Qmetis report might show that the team’s main shortfall is blood pressure management.

“Changing one thing out of a list of 20 is much easier than trying to analyze the entire process of TBI care and wondering what to do,” Dr. Ryken said.

4. Effectively educate staff on care protocols

Staff education is a key component of trauma PI. But effective education is a challenge for all programs. A flexible decision support tool can give immediate feedback to physicians and nurses, providing targeted education right when it is needed.

“For example, a lot of us trained years ago when all pediatric patients were hyperventilated. You succeeded in lowering the intracranial pressure, but shot yourself in the foot because you would not get good brain perfusion,” Dr. Ryken said. “Although this has been understood for a while, it keeps coming up. Targeted reminders on this issue are a much needed form of education.”

5. Track compliance and monitor performance

Monitoring ongoing performance is an important part of PI loop closure. Yet monitoring often requires time-consuming chart reviews — or simply waiting for problems to occur.

The Qmetis system provides an easy mechanism for monitoring compliance with specific protocols. First, run a quick report to check overall compliance with a specific treatment, monitoring activity or patient management threshold. Then, drill down as needed to check performance for specific shifts.

Qmetis can be customized with a center’s own clinical practice guidelines. So trauma leaders can use the system to support in-house protocols and monitor a broad range of PI interventions.

A fluid tool that provides security

“We have taken a very cumbersome and detailed set of guidelines and built them into a system that is extraordinarily easy to use,” said Harrison Frank, MD, chief medical advisor to Qmetis. “It doesn’t tell physicians what to do, it helps them make sure they are not missing anything in a high-stress environment. It’s a very fluid system that just adds to the flow of patient care.”

Would better guideline adherence help you improve patient outcomes? To learn more about the science of decision support and request a personal 10-minute demo, click here.