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PURPOSE
Deaconess Hospital’s Trauma Performance Improvement (PI) plan is to measure, evaluate, and improve the process and effectiveness of care rendered to the injured patient including medical oversight of pre-hospital providers, resuscitation, inpatient care, and inter-hospital transfer. This includes a multidisciplinary effort to monitor, assess, and improve both the processes and outcomes of care to the injured. The long-term goal is to decrease death and disability by reducing inappropriate variation in care through progressive cycles of performance review.

IDENTIFICATION OF PATIENT POPULATION
Criteria for determining which patients undergo monitoring and evaluation of care is correlated with the American College of Surgeons and hospital-specific indicators. See Trauma Registry Process Guideline for inclusion criteria.

STRUCTURE
The Performance Improvement consists of internal and external monitoring and evaluation of care provided by EMS, medical, nursing, and ancillary personnel, as well as hospital departments, services, and programs. Monitoring is ongoing and systematic; opportunities to reduce inappropriate variation in care are sought, and strategies to improve care are documented in the registry. The effectiveness of corrective action is evaluated through continuous reassessment and monitoring utilizing an ongoing performance improvement process.

RESPONSIBILITIES
The Trauma Medical Director, Trauma Outreach Medical Director, Trauma Performance Improvement Medical Director, Director of Patient Care Services, Trauma Program Manager, Trauma Data Quality Coding Coordinator(s), Trauma Clinical Operations Supervisor, Trauma Performance Improvement Nurse, and EMS Coordinator(s) address performance issues, which involve multiple services and departments. The Trauma Medical Director(s) leads the Trauma PI process through case reviews, participation in Multidisciplinary Trauma Rounds and review of variances, indicators, complications and complaints. The Trauma Medical Director will review events and determine corrective action if applicable.

The Trauma Clinical Operations Supervisor and Trauma Performance Improvement RN abstract data from selected patients’ chart concurrently, they identify and report complications, variances in care, complaints and opportunities for improvement from time of patient injury (EMS Care) through rehab. These issues are reported to the Trauma Medical Director/Trauma Program Manager and the Trauma Service team for concurrent follow-up needs. Each chart is screened again by the Trauma Data Quality Coding Coordinator(s) after discharge as appropriate.

The Trauma Data Quality Coding Coordinator(s) is responsible for report writing, and utilizing the Trauma Registry as the core source of information. He/she enters data into Trauma Base (Trauma Registry), State of Illinois Registry, and State of Indiana Registry assigns AIS codes, ICD-10 Codes and validates / enters E-codes for all injured patients who meet inclusion criteria. Issue, judgment, and action are documented in the patient’s trauma registry information by the Trauma Care Coordinator, Trauma Performance Improvement RN, Trauma Program Manager, and Trauma Data Quality Coding Coordinator(s).

Trauma cases are screened for physician review by the Trauma Program Manager, Trauma Clinical Operations Supervisor, and the Trauma Performance Improvement RN. Cases with complications, variances, or complaints may be reviewed by the Trauma Medical Director(s), Director of Patient Care Services, Trauma Program Manager, Trauma Clinical Operations Supervisor, Trauma Performance Improvement RN, and Trauma Data Quality Coding Coordinators as appropriate, then if warranted, forwarded to the Trauma Peer Review M&M committee. Trauma Services collaborates with the Deaconess Hospital’s Quality Improvement Liaison in screening mortalities, variances in care, and at risk cases. This communication between departments stimulates ideas and processes to ensure quality patient care. A representative from the Performance Improvement department attends the monthly Trauma Peer Review M & M committee meeting and reports back to the Medical Staff Quality Council if necessary.

The Trauma Operational Committee consists of a multidisciplinary team representing all phases of care provided to the injured patient including pre-hospital care. A representative from each of the designated trauma care areas is encouraged to attend and participate. These participants include: EMS, ICU, Medical Surgical, Orthopedic and Neurological Floors, Administration, ED liaison, Trauma Surgeon (TMD) and Trauma Services.

The Trauma Peer Review Committee meets monthly. This meeting is physician led, confidential, and peer protected. Peer physician representation includes Trauma Surgery, Vascular Surgery, Pediatric Intensivist, Emergency Medicine, Pulmonary Critical Care Medicine, Anesthesia, Radiology, Neurosurgery, Orthopaedic Surgery, and other appropriate physician sub-specialists. Cases that require further follow-up or action are referred to the Deaconess Medical Staff Executive Council or other department sections as necessary. Internal CME is available for Physicians at this meeting due to educational content, case reviews, and EBP reviews when indicated.

The Trauma Program Manager coordinates action planning and documentation between the trauma program and the hospital-wide PI program. Trauma Operational Committee and Trauma Peer Review M&M Committee meet monthly. System and process related issues are reviewed at the Trauma Operational Committee. Provider related morbidity and mortality issues as well as select complications are reviewed at Trauma Peer Review M&M Committee. The Trauma Service’s Department is responsible for data processing, analyzing, and reporting variances to the Trauma Operational and Medical Committees. As necessary, cases of educational merit are discussed with EMS, physicians, nurses and ancillary personnel and education credit given in compliance related to patient privacy regulations and peer protection requirements.

Trauma Services utilizes a three tiered system for trauma patient review. Each chart is screened to ensure patient care was delivered appropriately and timely (DVT prophylaxis, GI prophylaxis, c-spine clearance, timelines of treatments-OR, CT, ED, admitting orders, admitting MD, etc.) using a standard form/database. All deaths receive a Level 2 review completed by the Trauma Medical Director(s) and are presented at Trauma Peer Review Committee meeting for a level 3 review.

This guideline provides information on the resuscitative thoracotomy process in the Emergency Departments at Dunedin and Southland Hospitals.

Most patients with blunt thoracic trauma do not require surgery and are managed either with chest drainage and/or ventilatory support of some sort. Of those that do need an operation , the vast majority can be transferred rapidly and safely to the operating room.

Patients with penetrating trauma more commonly need surgical intervention but this should also be done in the operating theatre whenever possible.

Occasionally patients present in extremis with refractory shock or lose signs of life in, or just prior to arrival to, the Emergency Department. Some of these patients (notably those who have cardiac tamponade from a stab or other low energy penetrating wound) may survive if an Emergency Department thoracotomy is done and we need to be prepared for such an event, even though it is rare. An algorithm to guide decision-making is presented in Appendix 1.

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Philosophy of the Trauma Program

1. Geisigner Health System is an integrated health services organization widely recognized for its innovative use of the electronic health record and the development of innovative care delivery models such as Proven Health Navigator and ProvenCare®, Acute/Chronic Programs. As one of the nation’s largest health service organizations, Geisinger serves more than three million residents throughout 45 counties in central, south-central, and northeast Pennsylvania, and also in New Jersey with the addition of AtlantiCare, a National Malcolm Balridge Award recipient. The physician-led system is comprised of approximately 30,000 employees, including nearly 16,000 physicians, 12 hospital campuses, two research centers, and a 510,000-member health plan, all of which leverage an estimated $8.9 billion positive impact on the Pennsylvania economy. Geisinger has repeatedly garnered national accolades for integration, quality, and service. In addition to fulfilling its patient care mission, Geisinger has a long-standing commitment to medical education, research, and community service.
2. Geisinger Health System has had a long tradition in the provision of trauma care and has been recognized as a regional resource trauma center since 1986. Geisinger Health System and the Janet Weis Children’s Hospital are committed to the provision of adult and pediatric trauma care which fostered them to gain accreditation as a Level One Trauma Center with Additional Qualifications in Pediatric Trauma in 1996. The Janet Weis Children’s Hospital has been accredited as a Level Two Trauma Center since 2011. To accomplish these goals, Geisinger requires strong leadership with authority to coordinate the multidisciplinary team. The need to coordinate prevention programs and to direct research activities among many different specialties providing care to the trauma patient will impact the future direction of adult and pediatric trauma care in the country.
3. Geisinger Health System has and continues to be successful in its attention to traumatized patients by providing coordinated care throughout Geisinger departments and divisions. Geisinger Health System complies with the Pennsylvania Trauma Systems Foundation (PTSF) standards for Trauma Center Accreditation and is designated as a Level I Regional Resource Trauma Center by the Pennsylvania Trauma Systems Foundation. In 2012, Geisinger Health System became part of the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP). By utilizing ACS TQIP, Geisinger Health System is elevating the quality of care currently being delivered by members of the multidisciplinary team through the use of risk adjusted benchmarking based upon national comparisons. ACS TQIP also provides education and training to help Geisinger Health System trauma program to improve the quality of data and accurately interpret our benchmark reports.
4. The Division of Trauma Surgery falls under the Division of General Surgery. The expansion of our services includes not only adult and pediatric trauma, but emergency general surgery and surgical critical care. This service will permit enhanced patient services and facilitate a robust learning environment for residents and medical students.

MISSION
Harborview Medical Center provides trauma care to adults and children serving as a Level I adult and pediatric trauma center. Harborview is committed to providing the highest level of definitive care for injured patients, from resuscitation through rehabilitation. As the only Level I facility in a four-state region (Washington, Alaska, Montana and Idaho), Harborview participates in a regional system designed to ensure that every injured patient has access to the appropriate level of trauma care as soon as possible.

GOALS
The goals of the trauma quality improvement program at Harborview Medical Center are:

1. To provide a method of peer review oversight and evaluation of all aspects of adult and pediatric trauma care from pre-hospital care to rehabilitation.
2. To assist in providing the highest level of care and service to trauma patients, their families, pre-hospital agencies, referring providers and medical centers in the region. This includes peer review and feedback for care provided across the continuum of the trauma system.
3. To design, measure, assess and improve patient care processes and triage of adult and pediatric trauma care within the system.
4. To measure, assess and improve patient outcomes following traumatic injury. This includes establishing and implementing evidence-based guidelines for trauma care.
5. To evaluate and improve satisfaction of patients, patient families, staff, community, and licensing and accrediting agencies with the quality of trauma care at Harborview Medical Center.
6. To provide a forum that encourages presentation of errors or potential errors that is protected from legal disclosure, that is available to all health care providers, with the goal of system improvement rather than blame assignment.
7. The trauma Quality Improvement plan provides a mechanism for implementing these goals within the broader context of the hospital-wide Quality Improvement program and seeks to integrate with hospital Quality Improvement initiatives.

OBJECTIVES

1. Integrate and coordinate all trauma quality and performance improvement activities under the direction of the multidisciplinary Trauma Council, the Chief of Trauma Surgery and the Medical Director of Emergency Services.
2. Ensure that confidentiality of patient and provider information is maintained according to the standards of RCW 70.41.200 and 70.168.090
3. Provide feedback to prehospital EMS and air medical services and referring hospitals regarding patient care issues during transfer and transport.
4. Evaluate specific cases or problems identified in the monitoring process by peer review, through Departmental Mortality and Morbidity conferences, the multidisciplinary Trauma Council and provide an educational forum (Trauma Conference) for wide-spread dissemination of practice guidelines.
5. Use results from internal and external data collection measurement activities (e.g. audit filters) to study and improve processes and outcomes.
6. Develop standards of quality care for both adult and pediatric trauma.
7. Provide a process to monitor compliance with or adherence to the standards.
8. Provide processes for loop closure in correcting problems or deficiencies and measuring the effectiveness of corrective actions.
9. Identify, evaluate and impact pediatric Quality Improvement issues through the Harborview Pediatric Council.
10. Identify, and evaluate transitional and long-term outcomes of trauma care through the Harborview Rehab Council for adult trauma care and through the coordinated activities of the Harborview Pediatric Council and Seattle Children’s Hospital for pediatric care.
11. Use comparative data to benchmark performance of adult and pediatric trauma care to that of other Level 1 trauma centers.
12. Identify, evaluate and impact regional quality assurance issues through the Regional Trauma Quality Assurance Committees.
13. Partner with the Washington State Department of Health and EMS and Trauma Steering committee to implement evidence-based guidelines for trauma care statewide and evaluate system effectiveness and efficiency

SCOPE

1. The trauma Quality Improvement program applies to evaluation across the continuum from pre-hospital care to rehabilitation and re-integration of the patient into their community. The Quality Improvement program is applied to the full scope of trauma service including Prehospital care, resuscitation and evaluation, operative interventions, intensive care, short-term acute care and long-term/transitional care for adult trauma patients.
2. For pediatric trauma patients, Harborview is equipped to provide all resuscitation and evaluation, operative interventions, intensive care and short-term acute care services. In some cases, children require highly specific pediatric sub-specialty care, long-term/transitional care or pediatric inpatient rehabilitation services. For these patients, care is transferred to Seattle Children’s Hospital (SCH). The Quality Improvement program applies both to the initial resuscitation and acute phases of pediatric trauma care, as well as the long-term/transitional care through coordinated quality and performance improvement evaluations with SCH.
3. As the sole Level 1 trauma center for the region the scope of this QI program extends to the regional trauma system where we provide feedback to referring hospitals and serve as a resource for development of statewide patient care guidelines and assistance with QI initiatives and education across the region.

Abstract Trauma and other disease registries have been used to improve patient care and outcomes at the system level. Paradoxically, registries have had little role in informing the care of any individual patient while that care is being determined and delivered. The lack of timeliness of useful data is a major barrier to the value of registries in improving individual patient care real-time. What do trauma and emergency care providers require from their trauma registries to inform real-time patient tailored improvements in trauma care? Research is urgently needed to improve the usefulness of disease registries, and to develop innovative processes and applications using patient data to inform patient care real-time, thereby improving patient outcomes.

Each year approximately 5 million people die from injury globally, accounting for 9% of all deaths. Injury causes more deaths than human immunodeficiency virus (HIV), malaria and tuberculosis combined. Road injury alone ranks fifth among the leading causes of death. In Australia, where injury is one of nine National Health Priority Areas, it is the leading cause of death before the age of 45, with more than 10 000 deaths per year. Disproportionately affecting young adults, injury is the major cause of longterm disability and lost productivity.

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. 

A primary purpose of aggregating trauma related data across the nation and within a state is to provide data for research purposes and to have evidence to direct and improve treatment which can maximize positive outcome for the trauma population. Good data provides evidence for benchmarking and process improvement activities as well as a base from which to develop standards of care. In order to preserve data integrity, each data element must be collected, as closely as possible, by the same definition and according to the same guidelines by each facility that contributes to a state or national database.

The integrity and value of data entered into a trauma registry database will be directly affected by the training and expertise of the Trauma Registrar who abstracts, enters, and manages the data. The American Trauma Society provides a combined Basic and Advanced Course that should be considered the minimum necessary trauma registry training. Knowledge of medical terminology and human anatomy are also important especially in light of the scheduled implementation of ICD-10-CM in 2013. The focus of this manual is to provide clarity of definition and process guidance as the NTDB®, National Trauma Databank, national elements are entered into facility trauma registries for uploading into the state and national databases. Once the data has been entered in a facility trauma registry, the data will then be uploaded directly or be mapped to the corresponding fields at the state and national level; therefore, monitoring data mapping and understanding software functionality will be a necessary task for the trauma registrar in every trauma department.