Trauma program bolsters case for better equipment with benchmarking study
Trauma program bolsters case for better equipment with benchmarking study
Better performers use high-end equipment most
Gregory Jurkovich, MD, FACS, head of trauma at Harborview Medical Center in Seattle, contended that patients with severe head injuries did better when they had intercranial pressure (ICP) monitors.
But it is an expensive proposition that some might question. So it was gratifying to get support from national benchmarking data that the best trauma programs did just what his physicians did at Harborview, he says. The best performers in the University HealthSystem Consortium’s (UHC) trauma benchmarking study had a high percentage of patients with severe head injuries on ICP monitors, and Harborview’s use of them was at the top. (For more on the characteristics of better performers, see table.)
Table: Key Success Factors of Better Performers |
Case Study Site:
University of Tennessee, Knoxville. Areas of Outstanding Performance: Penetrating abdominal injury, overall trauma program |
• Trauma program one of three strategic business units • Hospital central dispatch activates trauma alert based on protocols • Trauma attending surgeons respond to all penetrating injury trauma cases • Active management of OR so room available for trauma cases • Implementation of penetrating injury practice guideline • Use of ED observation unit to evaluate stab wound injuries • Trauma coordinators provide case management and identify and follow up on system issues |
Case Study Site:
University of New Mexico Areas of Outstanding Performance: Penetrating abdominal injury |
• Trauma program one of three strategic business units • Hospital central dispatch activates trauma alert based on protocols • Trauma attending surgeons respond to all penetrating injury trauma cases • Active management of OR so room available for trauma cases • Implementation of penetrating injury practice guideline • Use of ED observation unit to evaluate stab wound injuries • Trauma coordinators provide case management and identify and follow up on system issues |
Case Study Site:
Oregon Health
Sciences University Areas of Outstanding Performance: Head injury with long bone fracture, overall trauma program |
• Emphasis on faculty-driven care |
Source: University HealthSystem Consortium, Oak Brook, IL. |
The results justify the expense
"We do this, and it’s expensive, but we believe it’s worth it," Jurkovich says. His next step is to prove that this high ICP monitor use, along with the use of daily CT scans on patients, has a positive impact on outcomes.
The data come from 57 hospitals within the Oak Brook, IL-based UHC and from outside the consortium. Data were collected in three categories, says Danielle Carrier, program director for operations improvement: an operational look at the overall program, clinical information from penetrating abdominal injuries, and head injuries with long bone fracture.
The operational data included basic information on the number of cases, the percentage of injuries that were penetrating vs. blunt, length of stay (LOS) in the emergency department (ED) prior to admission or transfer to the operating theater, and overall LOS. UHC also asked for information on who is included in trauma teams, the number of full-time employees in the trauma program, and data on the call program for attending physicians. Clinical indicators included information such as the time it took from door to femur fixation, the percentage of liver and spleen injuries that received operative vs. nonoperative treatment, and the use of ICP monitors.
The more patients, the better the service
In 1997, members were expressing interest in looking at improving trauma care while increasing efficiency, according to Julie Cerese, RN, MSN, director of clinical practice improvement for UHC. Among the key findings of the study:
• Of the average 1,400 trauma cases per year in a responding institution, about a third spend time in the intensive care unit, 41% have at least one operative procedure, and a quarter come from another facility.
• Average LOS is 3.7 days, and mortality rate is 1% for those with an injury severity score of 0 to 8. For those with a score of 25 or above, average LOS is 14.5 days, with a 37% mortality rate.
• Time in the ED for patients directly admitted ranges from 3.3 to 3.9 hours, depending on the severity score. Those going to the operating room (OR) are in the ED for 1.8 to 2.5 hours.
• Femur fixation occurs within about 25 hours of arrival in the ED.
• A quarter of severe head injury patients have ICP monitors.
• 65% of lacerated liver patients are treated without surgery, as are 56% of adult patients with ruptured spleens.
• Hospitals with trauma or critical care fellowship programs get patients out of the hospital between half a day and one day sooner than other centers.
There were some surprises, says Cerese. For penetrating injuries, some institutions’ patient management protocols may bypass the ED and go directly to the OR to expedite the patient through the system, she says. "But this may not be the ideal strategy, particularly in cases of low-level stab wounds."
Carrier says some of the results confirmed suspicions. For example, facilities that do the most trauma work achieve better results. Hospitals that are part of a trauma system also have better outcome. The message, she says, is to market your system so you get the kinds of numbers that create stellar trauma programs.
Get ready to work
Jurkovich admits that there was a lot of hard work involved in getting the data together. "We have to go out of our way to do this," he says, but adds that at least some of the data can be used for other regulatory and accreditation processes. "But all of us by nature like to compare ourselves to others, and we want to know how we are doing compared to everyone else. Just having a sense of doing a good job isn’t enough for us."
Maria Moore, MPH, coordinator of clinical projects at UHC, says having physician champions like Jurkovich helps get other doctors and staff on board. "They can help drive the project and help convey how useful the hard work will be in the end." It’s rarely a problem to get members on board if they have participated in at least one project. "That gets them over the hurdle."
Already, Jurkovich is working with the data that came from the knowledge transfer meeting. "We have shared them with the community of physicians that deals with these kinds of patients," he says. "We know that there are areas in which we stood out, and we are looking at those areas. The numbers and kinds of tests we do are on the end of the spectrum, and we have to determine if what we are doing is the right thing."
Next time, not so specific
When UHC revisits the trauma study again, it will take a broader look, Cerese says. "The penetrating injury population is an urban group," she says. "That limits the number of institutions that can participate because they don’t have the volume of patients." Only 26 hospitals could meet the volume necessary for penetrating abdominal injuries, she adds. "A lot of others just didn’t have the volume."
For the blunt injury, UHC was pretty specific about the kind of injury and the long bone fracture needed, Cerese continues. "In the future, we will extend the population so we can see how head injury is managed. We wanted the complicated patient, which is why we chose head injury and long bone. There was a sense that would be a big number. What they really had was head with pelvic, or head and foot, and concussions. We wanted something with a higher level head injury."
The study doesn’t just leave members with the data. It also includes recommendations and suggests opportunities for improvement. Among them:
• Develop a faculty- and attending-driven practice and a collaborative approach to delivery of care.
• Empower staff to avoid delays in delivery of care.
• Make use of practice guidelines to minimize care variations.
• Use protocols such as standard lab tests and response times to optimize resource utilization.
• Get patients out of the ED quickly.
• Use dedicated trauma nurses to actively manage care.
• Low-level penetrating injuries may not need surgery. Consider ED or 24-hour observations first.
• Start patients with penetrating abdominal injuries on antibiotics within two hours of incision.
• Use ICP monitors for patients with positive CT scans and patients with Glasgow Coma Scores of 8 to 12.
• Use dedicated ICUs to stabilize patients and ED observation units for low-risk trauma evaluations.
[For more information, contact:
• Danielle Carrier, Program Director, Operations Improvement, University HealthSystem Consortium, 2001 Spring Road, Suite 700, Oak Brook, IL 60523-1890. Telephone: (630) 954-1700.
• Julie Cerese, RN, MSN, Director of Clinical Practice Improvement, University HealthSystem Consortium. Telephone: (630) 954-1700.
• Maria Moore, MPH, Coordinator, Clinical Project, University HealthSystem Consortium. Telephone: (630) 954-1700.
• Gregory J. Jurkovich, MD FACS, Head of Trauma, Harborview Medical Center, 325 Ninth Ave., Seattle, WA 98104. Telephone: (206) 731-8485.
For more about the study, visit the UHC Web site: www.uhc.edu.]
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