Small hospitals can make big improvements

Emergency medicine may be practiced differently in large and small hospitals, but the process of quality improvement is the same in both. When problems are identified, new practices and protocols are put into place to help solve them. In the best scenarios, this leads to better outcomes and strengthens the commitment to improved care.

Jane A. Gisslen, R.N., director of emergency services at Mayo Clinic Health System in Red Wing, Minn., says her hospital began refining and refocusing its performance improvement (PI) process when it received its Level III Trauma Center designation in 2008.

"We had always done PI, but we really committed additional energy and resources with our designation," she says. "We started out determined that we would review all the cases that qualified for registry entry, even if they didn't have problems attached. We wanted to learn about all the admissions, transfers and deaths," she says. "We also looked at some state trauma suggestions. One was documentation of Glasgow Coma Scale scores, which we found needed improvement. It actually took about three years to get people to do it."

Since then, the process has continued to evolve. One current project focuses on the Southern Minnesota Regional Trauma Advisory Committee (SMRTAC) practice guidelines for spinal immobilization. The guidelines recommend removing patients from the pre-hospital backboard following the secondary survey — ideally within 20 minutes of arrival in the emergency department (ED).

"We want to get people off backboards if they don't need to be on them so they don't develop pressure sores and other complications," Gisslen says. "We have reduced the time our patients spend on backboards to 43 minutes. It still isn't where it needs to be, but we have cut the time in half and will continue this study moving forward, in conjunction with other SMRTAC initiatives."

The hospital also installed a video camera system to tape trauma team activations.

"Now we're looking at the team dynamics around activations, and how to improve the way we communicate so we have closed-loop communication," Gisslen says. "It's pretty exciting."

Improving performance in the field is another priority. After communication problems hampered response to a fatal accident near Red Wing, the hospital was part of a multidisciplinary task force that staged an emergency air and ground rescue simulation.

"We videotaped the whole thing, and it went remarkably well. It made us feel so good about what we're doing for process improvement, and it also enhanced our relationship with our colleagues in EMS and air transport and with our tertiary center contacts. You don't really understand the depth as well as the value of relationships until you're doing process improvement and you see how you relate and work together," Gisslen says.

The process

The hospital has a core trauma group that includes surgeons, the ED medical director and ED director (Gisslen), a trauma director, radiologist, and ICU and trauma registry nurses, as well as a representative from the local emergency medical services. The trauma group as a whole decides which cases to review. Some issues require feedback or action; others are watched and tracked. The aim is always to identify gaps in knowledge and practice.

But performance improvement is more than chart review, documentation and diligence, says Gisslen. It's also about looking around the community and seeing what can be done better.

"In a small community you have to do a good job because you're likely to see your patients on the street. It's an additional impetus when you choose to practice in a setting where you can get to know people in the context of their lives and follow what happens to them."