Concurrent review of nonsurgical admissions (NSAs) allows trauma program staff to identify opportunities to optimize care while the patient is still in the hospital. However, many trauma centers struggle to operationalize concurrent inpatient review.
According to Ginger Knapp, MSN, RN, CEN, one key to solving this challenge is to leverage the trauma registry to organize information on NSA patients and drive timely care interventions.
Knapp is the trauma program coordinator (TPC) for Froedtert Menomonee Falls Hospital and Froedtert West Bend Hospital in Southeast Wisconsin. Both trauma centers have an NSA rate of approximately 90%, so concurrent inpatient review is essential to ensuring quality care for injured patients.
Team approach to concurrent review
Both Froedtert Menomonee Falls Hospital and Froedtert West Bend Hospital are state-designated Level III trauma centers, admitting mostly orthopedic injuries and single-system trauma. Each hospital receives approximately 700 trauma patients per year, and more than 75% of these patients are geriatric ground-level falls.
“Our admitted patient population is typically geriatric with numerous co-morbidities,” Knapp said. “Our hospitalists do a great job of managing the medical components of these patients in collaboration with orthopedic and/or trauma surgery consultants. With that, we also recognized that we have a high NSA rate — and that implementing a concurrent review process was key to making sure we look at all injured patients with a trauma lens.”
According to Knapp, past efforts to implement concurrent review at the hospitals were not efficient. One attempted solution was an audit form for NSA trauma patients.
“The form listed several key PI items and protocols,” Knapp said. “The emergency department RN was tasked with identifying injured patients and sending the audit tool to the floor with the patient. The expectation was that the floor nurse would then complete the audit tool and return it to the trauma program coordinator.”
Unfortunately, compliance with this approach was low. “There were several areas of breakdown,” she said. “Often the form was not sent with the patient. Other times the form was never completed, or the form never made it back to the trauma program.”
Knapp believed the trauma registry was the key to an efficient and effective solution. So she worked with one of the program’s trauma registrars to develop a new process built on registry software capabilities:
Registrars identify admitted trauma patients. The trauma registrars manually review EMR reports every morning to identify patients with traumatic injuries who were admitted to the hospital. Cases are identified through two reports — a report of all “trauma starts” in the ED and a report that lists all ED patients either transferred or admitted. For every patient identified, the registrars start a record in the trauma registry. They also enter basic patient demographic information into a spreadsheet that is linked to a PI spreadsheet maintained by the TPC.
TPC reviews admitted patients and follows up as needed. The PI spreadsheet is simple — patient names and MRNs only. It serves as a backup case list, as all performance improvement records are kept in the confidential registry PI section. Working from the spreadsheet case list, the TPC goes into the PI tab of the patient registry and places an indicator titled “admit.” The notes section within the “admit” PI indictor is used for reviewing admitted trauma patients and following up as needed. For example, if a patient was admitted for a minor intracranial bleed and did not have a repeat head CT by 9 a.m., Knapp will call the physician requesting the order. Or if a patient is admitted with rib fractures but the chest trauma protocol is not ordered, Knapp will contact the care team to have the appropriate order placed.
TPC documents patient reviews in registry. Knapp has configured the trauma registry dashboard to include a list of open cases that are currently admitted. This makes for an efficient way to identify admitted patients needing daily review. Knapp documents her case notes concurrently in the registry’s PI section. The PI notes reflect the intervention completed, conversations and review completed. (The PI section of the patient registry is not accessible to anyone other than trauma program staff.) If a complication was noted during her review or an audit filter was triggered, she will add the additional audit filter immediately to the registry record.
Team performs full abstraction and follow-up PI. Registry cases without audit filter fallouts are closed upon patient discharge. If any audit filters were triggered, Knapp immediately escalates the case in accordance with the PIPS plan. At approximately the 30-day mark, a trauma registrar will perform a full abstraction on the patient chart. If any new issues or audit filters are identified by the registrar, the case will be emailed to Knapp, who will then perform an additional review.
“The end result is that our program does both a concurrent review and, as needed, a retrospective review of our NSA trauma patients,” Knapp said.
Reliable results with greater efficiency
The new process was introduced in July 2020, and it has proven to be an effective system for ensuring concurrent review of trauma patients admitted by a nonsurgical service.
“In our centers, all admitted patients receive a concurrent review,” Knapp said. “And since this process is more efficient, it has allowed the trauma program to focus more on performance improvement initiatives and providing real-time feedback to the care teams.”
In addition, using the registry to facilitate concurrent review helps trauma program leaders track PI projects and prepare for site visits. It also creates the opportunity to optimize patient care.
“It is important to make sure we are actively reviewing cases to ensure care is appropriate,” Knapp said. “And when you review cases concurrently while cases are actively admitted, you can actually mitigate problems coming down the line because you can act on them immediately and prevent them from happening at all.”
She noted that in the event a complication or concern comes up during admission, a concurrent review process allows the trauma program to gather information from the care team in a timely manner to identify opportunities for improvement.
According to Marshall Beckman, MD, trauma medical director at Froedtert Menomonee Falls Hospital, real-time information is key to optimizing patient care.
“As trauma program managers and medical directors, we have an obligation to provide the best trauma care possible,” Dr. Beckman said. “This means that if there is a problem with how our program is functioning, we need to know in real time so that changes can be made. Our use of the trauma registry allows real-time evaluation and change while maintaining peer review protection.”