Manage levels of review more efficiently with event review templates

The “levels of review” model was created to make trauma performance improvement (PI) more efficient. In many trauma programs, however, managing events through the levels of review is a complicated process that absorbs time and attention. At times, it feels like the process creates additional work without providing additional benefit.

In my experience, the solution is to develop event templates that focus the review process and facilitate decision-making. I will explain this idea in detail below. But to get an overall understanding, consider this analogy:

• When a general surgeon has to resect a tumor, step one is to obtain extensive imaging studies. The idea is to create a roadmap that shows exactly where to go and what to do. The goal is precision.
• When a trauma surgeon has to control internal bleeding in a hypotensive patient who is too unstable to go to CT, step one is to do a quick FAST exam. The idea is to go as rapidly as possible to the OR for a trauma laparotomy with a large midline incision. The goal is speed.

My suggestion — although it may be counterintuitive for us in trauma — is that trauma PI should be less like trauma surgery and more like general surgery.

In other words, when a PI event comes to our attention, we should not immediately start combing the chart for shortfalls and protocol variances. Instead, we should follow a roadmap designed for evaluating common PI events — an event review template that assists in drilling down on events with consistency

Event review templates allow trauma program leaders to close more events at primary and secondary review, and they make secondary review meetings more efficient. In the process, they free up time for corrective action planning and loop closure. Event review templates can also be a great tool for orienting new trauma program staff who may not have the luxury of receiving a proper hand-off from their predecessor.

How to create and use trauma PI event review templates

The basic idea is to identify the key information needed to resolve your trauma program’s most common complications, PI audit filters and events. There are four elements:

A clear definition of the complication or event. The definition should mirror the National Trauma Data Standard (NTDS) Data Dictionary and align with your center’s own performance improvement and patient safety (PIPS) process and clinical practice guidelines.

The clinical information necessary to review care. What does the trauma medical director (TMD) need to know about this patient and the care they received in order to make a determination?

The level of review at which the event can be resolved. Is this an event that must go to secondary review, or can it be closed in primary review?

Clear parameters for determining patient harm. In general, what do minimal harm, moderate harm and severe harm look like for patients with this complication?

Following is an example of an event review template for acute kidney injury (AKI), a common complication among trauma patients:

The defined levels of harm and drill-down questions outlined above allow the TMD along with the TPM or PI coordinator to make timely and consistent decisions about AKI events.

Note that “level of harm” is key. In this example, a patient who had elevated creatine but was asymptomatic could normally be closed at primary review. On the other hand, a patient who required a nephrology consult and/or advanced interventions would be referred for secondary review.

In general, events with minimal patient harm can be closed by the TPM or PI coordinator at the primary level of review. All moderate harm events should be reviewed by the TMD during secondary review and may need to advance to tertiary review as well.

For events that need to advance to secondary review, the template provides clear guidance on how to prepare for the review meeting. Again, the consistent drill-down questions outline everything the TMD will need to know about the case to make a determination and an appropriate corrective action plan.

What are we trying to avoid? We all know that secondary review meetings can easily get bogged down by information gaps. The meeting starts with the TPM or PI coordinator presenting the AKI patient. The TMD asks what the creatinine was before the patient was admitted. No one knows, so they open the electronic health record and start searching. Similar questions arise regarding details of the resuscitation and later care on the floor. Multiply the process by four or five patients and you have a meeting that takes hours.

In contrast, if the PI team goes into the meeting armed with all the salient details, case review can be handled quickly and efficiently. Meeting participants are equipped to make better decisions. Everyone spends less time hunting for information and more time discussing how to actually improve care.

This template is an ideal tool for new TPMs or PI coordinators, especially in situations where high turnover leads to inadequate staff transitions. It is also helpful for program leaders in startup trauma centers.

What to keep in mind

Ideally, a trauma program will develop review templates for each of its 20 to 30 most common PI events. This could include delays in care, clotting or bleeding complications, unplanned interventions, hospital-acquired infections, and other complications and audit filters.

Assemble all the templates in a single spreadsheet. Again, each event template should include the event definition based on the NTDS Data Dictionary and the center’s own clinical practice guideline compliance parameters.

Be sure to customize the event review template spreadsheet for your trauma center. This tool will be most useful if it addresses the complications that your center sees most often. It is a fluid tool that may need revision based upon new evidence-based medicine.

In addition, the drill-down questions should cover your center’s specific issues and opportunities for improvement. For example, your event review template for MTPs might reflect specific obstacles your center faces, like incorporating TEG into your protocol.

The templates should also reflect your center’s specific PI priorities. For instance, if your center is trying to improve identification and treatment of extremity compartment syndrome, create a review template that defines levels of harm and drill-down questions for this complication.

Note that the “level of review at which an event can be closed” documented in your event review templates must reflect your center’s PIPS plan. If your PIPS plan states that all delays to the OR must go to secondary review, your review template cannot list this event as closable at primary review. On the other hand, realize that you can revise your PIPS plan (if appropriate) to allow an efficient approach to levels of review.

Creating event review templates will take time. However, many of the data points covered by your drill-down questions are already required for your center’s TQIP submission. In addition, if you build your drill-down data points into your trauma registry, you can easily prepare for secondary review meetings by simply running a registry report.

Do more in less time

Expectations for trauma centers are increasing, but not necessarily the available resources. PI event review templates allow TMDs, TPMs and PI coordinators to accomplish more in less time. They allow trauma program leadership teams to spend less time in chart review and more time on high-value activities that improve patient care.

Kathleen Martin, MSN, RN is a trauma system consultant who develops trauma centers and trauma systems globally. Previously, she served as senior director of trauma services at UCHealth (Colorado), where she had responsibility for four trauma centers. She has also served as trauma nurse director at Landstuhl Regional Medical Center, Germany (the first ACS-verified trauma center outside the U.S.) and trauma program manager at the Hospital of the University of Pennsylvania. Kathleen currently serves on the board of directors of the American Trauma Society (ATS), chairs the ATS Nurse Leadership Council and teaches the ATS Trauma Program Management Course. She served for 19 years as a board member of the Society of Trauma Nurses (STN) and was the 2000-2001 STN President. She was also Editor-in-Chief of the Journal of Trauma Nursing. In addition, she was a charter developer of the TOPIC course and has developed a number of far-reaching trauma PI processes. As a consultant, Kathleen has mentored trauma professionals nationally and internationally and has presented trauma education for colleagues in Europe, the Middle East, South America and Australasia.