Proposed regional PI process would be open to all
The purpose of regional trauma performance improvement (PI) is to systematically review and improve outcomes of trauma care across the continuum. The focus is not only on the system as a whole but also on individual components, including prehospital triage, interfacility transfer, and hospital and rehabilitative care.
Because the ultimate goal is to identify opportunities for improvement, the overarching question should always be, 'If faced with this same situation in the future, is there anything we could do better?' says Debra (Deb) E. Horsman, M.S., R.N., coordinator of the Southern Minnesota Regional Trauma Advisory Committee (SMRTAC).
In the past, that process was relatively informal. "At our general meeting, people would come up and report various problems — for instance, a lack of communication among local ambulance services or a small hospital admitting a trauma patient needing a tertiary level of care. But there was no formalized regional PI plan, and although we had a PI subcommittee, it wasn't very robust," she explains.
Now, plans are in the works for a system would allow anyone wanting to report a regional PI issue to complete a case review request form. The form asks for the date of the occurrence, a description of what happened, what the requester would like to see evaluated and any action already taken to try to resolve the issue. This form would begin the process for an inclusive, multidisciplinary regional review that would look for opportunities for improvement.
The SMRTAC coordinator, medical director or both would consider whether the submitted issue would be better managed internally or is pertinent for regional review. If the latter, the issue is submitted for a secondary review to one of the co-chairs of the PI subcommittee. That person then determines whether the issue should be put forward to the full PI committee for tertiary level review. Members of the PI committee include pediatric specialists, representatives from Emergency Medical Services (EMS), medical transport and critical access hospitals in addition to subcommittee members.
The PI committee then decides on an action plan, which may include education, discussion or feedback, tracking of a trend, the development of practice management guidelines (PMGs), or periodic review. Quality improvement literature shows that system factors are the most common cause of adverse events and require system action plans to address them. In some cases, the issue may be referred to the state trauma system or the regional trauma system advisory committee leadership forum for action.
SMRTAC has a long track record of tackling regional issues to improve patient care. One result has been a significant reduction in the number of stage III decubitus ulcers. The change is the result of PMGs for adult and pediatric spine immobilization that discourage the use of longboards for trauma patients except in cases of spinal cord injuries.
The guidelines also mandate that patients in the emergency department must, in most cases, be removed from spine boards after the primary and secondary survey — ideally within 20 minutes and before any imaging.
Another key issue is length of stay, Horsman says. "We needed to reduce the time from injury to arrival at the first hospital and the time spent there until the patient was out the door to definitive care," she explains. "Before we adopted trauma team activation criteria in 2014, the time from injury to a small hospital to Mayo was almost four hours — long past the golden hour. Under the new guidelines for highest tier trauma team activation patients, the decision to transfer should be made within 20 minutes."
Other audit filters — complications that bring a case forward for review — include reversal of anticoagulation in patients with traumatic brain injury.
"We had patients with head bleeds who were on anticoagulants, so we instituted a regional protocol to reverse anticoagulation before transport," Horsman says. "Most hospitals have vitamin K on hand, and Mayo One also carries thawed plasma, which has been shown to reverse anticoagulation in the prehospital setting."
Efforts to improve quality need to be measured to determine if they produce the desired outcomes. But much of the data that would allow SMRTAC to track the effect of initiatives is unreliable or unavailable.
David S. Morris, M.D., a trauma surgeon at Mayo Clinic's campus in Rochester, Minnesota, points to technical glitches with the state trauma registry — and the data entry burden on small hospitals — as well as the difficulty of dealing with de-identified data.
"For real, robust and meaningful PI on the regional level, you have to look at the whole incident across the continuum," he says. You need to access the data of each entity, and right now, we can't do that."
Still, Dr. Morris and many others are working on fixes, including a simplified data entry system specific to Level III and IV centers. Another solution, Horsman says, is to "employ our own data company; if we pay for the data, we own it."
In the meantime, the regional PI process is gearing up. Regional trauma performance improvement review request forms will be available on the SMRTAC website.