Items tagged with 2018

Trauma Center History
Trauma Care has evolved into a specialty in many local and regional hospitals over recent years. Historically called emergency rooms, trauma centers have established high quality, comprehensive medical services for patients. The public relies on trauma centers to provide quality care from initial injury to final disposition, whether at the local hospital or tertiary care center. Regardless of where the trauma program is located, it provides critical services in a timely manner to patients who often need lifesaving measures. As a Trauma Program Manager (TPM), it is a primary responsibility to ensure patients are receiving the best care possible. This is often accomplished by compilation and analysis of data, policy review, and continuous quality improvement initiatives. The following chapters will provide an overview of many aspects of trauma care and acts as a guide to help the TPM succeed in their role. TPM will be referenced throughout the manual and will be the collective title for the role.

Trauma Center Levels
The verification of trauma levels is important in qualifying what essential services are offered at a hospital. The Iowa Department of Public Health (IDPH) is responsible for the verification, or re-verification, of each Level III and IV hospital on a three-year cycle. Criteria from the American College of Surgeons Committee on Trauma (ACS-COT) is utilized to ensure consistent practice standards and available resources. Basic definitions of each trauma level are outlined below. 

INTRODUCTION
A systems approach to trauma care provides the best means to protect the public from premature death and prolonged disability. Trauma systems reduce death and disability by identifying causes of injury and promoting activities to prevent injury from occurring, and by assuring that the resources required for optimal care are available. A major goal of trauma care systems is to provide care that is efficacious, safe, and cost-effective.

Performance Improvement and Patient Safety (PIPS) in an organized trauma system consists of multiple layers of continuous monitoring and evaluation of care to identify opportunities for improvement. This progressive cycle of evaluation extends from the performance improvement (PI) programs of hospitals and emergency medical services (EMS) agencies to review committees established at the state and regional levels, and evaluation programs within the MSDH including the Mississippi Trauma Registry (MTR).

This model emphasizes a continuous, multidisciplinary, multi-layered effort to monitor, measure, assess, and improve the process and outcomes of trauma care. Regardless of the hospital, service, or region, care processes and the clinical management of trauma patients must be evaluated using an established methodology with pre-defined measures based on national or state recognized standards. This review should include comparison and benchmarking of services, hospitals, and regions with state or national data obtained through trauma registries, mortality studies, and outcomes-related research.

This plan was developed to assist and guide trauma committees responsible for PIPS within agencies, institutions, or regional and state systems. Each section provides PIPS advice for each level of responsibility and is written to stand separately as a guide for that level. As a result, there is some duplication of information throughout the manual. The appendices offer explicit examples and language for PIPS activities which may be adapted. Adhering to the processes described will provide a foundation for a successful trauma center and system PIPS program but is not considered a replacement for a consensus process under the direction of a Trauma Medical Director and Trauma Program Manager. Mississippi Trauma Care System

Other resources to consult as efforts to implement trauma PI statewide evolve include:

• “PIPS Reference Manual” (ACS 2002)
• “Resources for Optimal Care of the Injured Patient” (ACS 2014)
• Advanced Trauma Life Support Manual (ATLS)
• Evidenced based practice guidelines or reviews
• American College of Surgeons
• Eastern Association for the Surgery of Trauma (EAST)
• US Department to Health and Human Services
• Agency for Healthcare Research and Quality (Evidenced-based Practice Program)
• National Guideline Clearinghouse

Together with this plan, the advice of those resources should result in activities necessary for improving trauma care locally, regionally, and state-wide. Seeking the regular advice of professionals with expertise in trauma PI is strongly recommended to assure that PIPS processes meet contemporary theory and comply with State law governing protection of clinical care review.

It is acknowledged that modifications and adaptations of this model will occur to allow for the unique characteristics of trauma care provision in each MS Trauma Care Region.

1976 was a key year in the evolution of care of the injured patient. In that year, Dr. Donald Trunkey and the American College of Surgeons Committee on Trauma (ACS COT) laid out the first list of criteria to define the essential elements of a trauma center. This simple optimal resources document led directly to the development of the ACS COT’s Verification Review and Consultation (VRC) program, which has grown to 510 verified trauma centers across the United States. The same year, orthopaedic surgeon Dr. James Styner and his family were tragically injured in a plane crash in a rural Nebraska cornfield. The lack of trained personnel and resources available to care for his family compelled Dr. Steiner and his colleague, Dr. Paul “Skip” Collicott, to develop “Advanced Trauma Life Support (ATLS)”, with the goal of ensuring that surgeons providing injury care would know what to do when confronted with an injured patient. ATLS was quickly adopted and aggressively promulgated by the ACS COT, and has grown to become a global movement. The first course was held in 1980, and since that time ATLS has been diligently refined and improved year after year, decade after decade, with more than a million students taught world-wide.

These two programs, the VRC and ATLS have transformed the care of injured patients across the globe, resulting in hundreds of thousands of lives saved. Although ATLS was intended as an educational program, and the VRC was intended to be a set of standards, ATLS has standardized the care of trauma patients and the VRC educated the trauma community in the US on how best to provide optimal care for trauma patients. Now 60% of ATLS classes are held outside of the US, taught by local faculty based on the same central principles. By contrast, the concept of trauma center verification established by the VRC as not been established outside of the US.

Ultimately, reducing injury death and disability at a public health level requires a multifaceted, integrated approach, one that includes prevention, prehospital care, a network of definitive care facilities, and resources for rehabilitation. While training providers in injury care is an essential step, trained providers have limited impact without the other essential elements of a trauma system, especially a network of capable trauma centers. The development of a trauma system cannot be driven by ATLS education alone; an organized trauma center verification program, such as the VRC, is equally critical.

In 2015, Dr. Maria Fernanda Jimenez, the Chair of the International Injury Care Committee (I2C2), reached out to the ACS COT asking to move forward with a translation of the current Optimal Resources for Care of the Injured Patient 2014. This initial aim of translating the document led to a discussion involving the ACS COT Executive Committee, the Trauma Systems Evaluation and Planning Committee (Robert Winchell) and the Verification, Review and Consultation Committee (Rosemary Kozar) to discuss the strategy and goals of the project. Following these discussions and with the unanimous support of the ACS COT Executive Committee, a pilot program in Region 14 (Latin America and the Caribbean) moved forward with three primary goals: 1) translate the Optimal Resources document to Spanish and Portugese; 2) use the translated document as a framework to establish a verification system relevant to Latin American and the Caribbean; and 3) pilot a verification process and structure in the Region. It was recognized that the Optimal Resources for Care of the Injured Patient 2014 standards could be literally translated; however, the processes and requirements would not be directly applicable to another country or region outside the US due to a wide variety of cultural and societal differences (e.g. laws, professional certifications, culture, and specific resource availability). Although the ACS COT Executive Committee and the leadership of Region 14 recognized not all the specific criteria would be directly relevant or applicable to the Region, Dr. Jimenez and the surgeons in I2C2 and Region 14 committed to a trauma center/system verification process modeled on exactly the same principles established in the United States: 1) setting relevant, high standards which elevate care; 2) ensuring the right resources, structure, processes and leadership are present; 3) using clinical data (ideally risk adjusted) for performance Improvement and outcome assessment; and 4) verifying that the standards are being met by an independent, rigorous and objective external review by clinical experts.

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Introduction:
This policy describes the Trauma Service Performance Improvement and Patient Safety (PIPS) plan at Medical Center of the Rockies (MCR).

Scope:
View the UCHealth Policy Scope Statement to see where this policy applies. This policy applies to Medical Center of the Rockies.

Philosophy of the Trauma Program
The trauma program provides a coordinated multidisciplinary approach to patient management throughout the continuum of care from pre-hospital to rehabilitation. The management of multiple, complex injuries require a team of individuals with expertise in a number of areas. A coordinated team approach prevents unnecessary delay in care, missed injuries, conflicting treatment plans, inappropriate management, disability, and death. The multidisciplinary team leader is the trauma surgeon. The trauma surgeon not only contributes specific care in the area of his or her specialty, but also oversees and coordinates the care provided by the other consulted disciplines. The Trauma Medical Director (TMD) will interpret and reconcile any conflicts in the recommendations of team members and consultants.

Mission and Vision of the Trauma PIPS Program
The goal of the Trauma Performance Improvement and Patient Safety (PIPS) program is to provide a systematic framework to support the improvement of trauma patient care and outcomes through continuous monitoring, and assessment of structures and processes, followed by the implementation of an action plan when an opportunity for improvement is identified. The results of changes are then followed by reassessment to ensure loop closure.

The Trauma Service is committed to providing measurable, high quality, cost-effective health care through active involvement of all medical and hospital staff.

Purpose and Objectives:

• To integrate and coordinate all trauma performance improvement activities throughout the hospital.
• To identify and resolve interdisciplinary process problems, prevent duplication of efforts and facilitate communication.
• To utilize continuous quality improvement concepts/techniques to improve selected processes and systems.
• To utilize external reference databases to monitor performance and to assist in setting priorities for improving performance.
• To shift the primary focus from the performance of individuals to the performance of the trauma system’s processes and systems, while continuing to recognize the importance of the individual competence of all team members.
• To maintain current written standards of professional practice and related policies and procedures that demonstrate compliance with both internally and externally established standards and regulations.
• To integrate the standards from the Colorado Statewide Trauma Care Systems Act, the American College of Surgeons’ Committee on Trauma, and the Joint Commission.

Issue identification

• Trauma patient’s length-of-stay in ED was 90 minutes. Delayed transfer due to radiological studies performed before transfer.

Specific goal & measure of achievement

• Trauma patient requires transfer out of ED within 60 minutes
• Ninety percent of the time

Analysis w/data (when available)

• Eight of 15 cases (53%) met 60-minute standard

Develop and implement action plan

• Send case to peer review; review trauma transfer protocol, discuss rationale for refraining from obtaining studies that do not impact the resuscitation, etc

Evaluation, re-evaluation, re-re-evaluation

• Trend, measure performance and strategize solutions
• Six months later 10 out of 12 new cases (83%) met 60- minute standard. >>> New action plan, continue to trend and measure performance

Loop closure

• Goal attained; action(s) resulted in goal attainment
• Eight months later 12 of 13 cases (92%) met the goal.
• Once goal is attained, can close the loop or continue to trend to verify continued success.