The Quality-Cost Connection
Improve performance in trauma care
By Patrice Spath, RHIT
Forest Grove, OR
Many states have adopted trauma program legislation that includes a statewide trauma registry and performance evaluation activities. Hospitals participating in the trauma network are required to support the statewide activities through submission of data about the trauma patients they treat. In response to state statutes, designated trauma centers have established an internal trauma registry to collect information about trauma care experiences. The registries document, at a minimum, the severity of a patient’s injury upon arrival and the outcome of care (survival, length of intensive care unit stay, and hospital stay).
The data are used to evaluate the hospital’s trauma care experience. Regular multidisciplinary trauma conferences that include all members of the trauma team are held. By analyzing the quality of care provided to trauma patients, the trauma team members work to improve their services. Overseeing many trauma programs is a medical staff trauma committee that includes physicians and administrative and staff representatives from each of the trauma care disciplines.
The first step toward identifying performance measures for the hospital trauma program is to describe the scope of care and services. Because quality of care is strongly influenced by many disciplines, it is best to take a "key functions" approach when identifying performance measures. What are the key functions of trauma patient care that have the greatest impact on the quality of care the trauma patient ultimately receives? These key functions may include: medication use, blood use, infection control, diagnostics, clinical decision making, nursing care, use of surgical and other invasive procedures, and nutritional support.
Using the key functions as the foundation, the trauma program leaders then select those important aspects of care that should be monitored regularly. Input in the measurement selection process should be obtained from each group of professional disciplines that provide care for trauma patients. Obtaining multidisciplinary input in this process ensures that the entire continuum of trauma patient management is covered.
Although many important aspects of trauma care can be identified, the resources of the organization may prohibit evaluating each aspect all the time. Therefore, the trauma committee should consider prioritizing the review activities. Some critical elements of trauma care may be routinely evaluated while other aspects may need only periodic evaluation.
Examples of important aspects of trauma care as they relate to the key functions include:
- Timeliness of test completion
- Appropriateness of diagnostics chosen to evaluate patients’ presenting symptoms
- Trauma patient, comatose upon hospital arrival, receiving CT scan > 1 hour after arrival
Clinical decision making
- Physician management of the comatose trauma patient
- Physician management of the trauma patient with dyspnea
- Use of mast trousers in trauma care
- Postoperative nutritional assessment/ management of hospitalized trauma patients
- Use of preoperative nutritional supplements for the severely malnourished patient
- Availability of necessary drugs in the emergency department
- Management of patients requiring chemical paralysis
- Appropriateness of drug use during cardiopulmonary resuscitation
A number of performance measures can be used to monitor the quality of trauma care. These indicators are cross-departmental because of the multispecialty aspects of trauma patient management. (For examples of measures that might be useful to the trauma program’s assessment process, see "Occurrence screens and performance measures for trauma services," in this issue.)
Some of these measures are occurrence screens that can be used to identify important single events needing more in-depth review by the trauma committee. Other measures provide rate-based information useful for ongoing monitoring activities. A more extensive analysis is done only when the measurement result triggers a pre-determined threshold or when the aspect of care is selected for improvement activities.
In addition to ongoing performance evaluations, the trauma committee may periodically conduct focused studies of particular topics of interest. Listed below are two examples of trauma care study topics and evaluation criteria that may be used to assess the adequacy of nursing care for trauma patients:
Study topic: Nursing management of the comatose trauma patient
- Cases with complete set of vital signs, repeat as needed
- Cases in which admission evaluation of patient’s airway is documented
- Treatment delays attributed to unavailability of suction equipment
- Cases in which initial nursing assessment includes patient history obtained from family/ emergency medical technicians (previous history, precipitating illness or fever, chronic illnesses)
- Patients with peripheral IV line within "X" minutes of emergency department arrival
Study topic: Nursing management of the trauma patient with dyspnea
- Cases with inadequate nursing documentation of patient’s current symptoms and history of respiratory status
- Cases lacking documentation of patient’s home oxygen use (present or absent)
- Cases lacking oximetry testing within "X" minutes of patient’s distress
- Cases with in adequate documentation of vital signs every hour or more often, as patient condition requires
- Patients not placed on cardiac monitor
- Cases lacking documentation of patient’s skin temperature, color, and consistency
Whether your facility is designated as a Level I, II, or III trauma center or has no trauma designation, evaluating and improving the quality of care for accident victims is an important interdisciplinary activity. Designated trauma centers usually are required by state regulations to track injuries and treatment of patients in the hospital. However, there are many hospitals in large urban population areas as well as rural sites that provide care for trauma victims but have no trauma center designation. Even if your organization is not officially recognized as a trauma center, evaluating the quality of care provided to accident victims is an essential performance improvement activity. Anecdotal information about undesirable events or occurrence screening of cases does not provide sufficient information to ensure that trauma care is adequately being evaluated and improvement opportunities identified. That’s why routine monitors of important aspects of trauma care and periodic focused studies should be conducted.
[A suggested resource, Trauma Performance Improvement: A How-To Handbook (2000) by the Committee on Trauma of the American College of Surgeons is available free on-line at www.facs.org/dept/trauma/handbook.html.]