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Performance Improvement

Every Kentucky Trauma Center hospital is expected to measure, evaluate and improve its performance with respect to numerous objectives in health care from patient care standards to fiscal solvency to materials management. A successful performance improvement process is designed to identify weaknesses within an organization that prevent the organization from providing the optimal care it is capable of providing.

The process used to facilitate performance improvement may be referred to by other names, such as quality assurance or continuous quality improvement. Regardless of by what means your facility employs, it is important that there be a process in place to provide an intentional process, or loop, to continuously identify shortcomings in patient care, determine the likely cause, employ a plan to correct it, then evaluate whether or not the shortcoming has been resolved, thus ―closing the loop.‖ A PI program will assist your facility to constantly improve itself by identifying and confronting problems within the institution. The process can be applied to virtually any element of performance within the hospital.

PI Structure

While the required PI components must be in place in a trauma hospital, the structure is left to the discretion of the facility and will depend on the facility size and available resources. It is anticipated that hospitals have an existing PI structure in place. The trauma program PI activities ideally are incorporated into that structure. The description of the PI process contained herein is not meant to be prescriptive, but illustrative. It is understood that facilities will accomplish PI in a variety of ways. Trauma center are expected to be able to demonstrate the effectiveness of their program.

The trauma program should have a standing trauma PI team, usually made up of the trauma program manager/coordinator, the trauma services medical director and possibly the trauma program registrar. All information and reports pertaining to trauma program performance are funneled through this team. The data is then either used by the team to address system concerns or referred to one or more PI committees to address patient care concerns.

Both system and patient care-related issues can be identified via several methods.

• Chart abstraction
• Emails
• Hallway conversations
• Hospital information/database systems/registries
• Individual patient charts
• Multidisciplinary committee meetings
• Patient relations inquiries/complaints
• Personal observations
• Rounds
• Staff reports

The Kentucky Trauma Registry (KTR) was established by state law (KRS 211.490 et seq.; 902 KAR 28:040) to be the statewide repository for trauma data. It is housed administratively in the Kentucky Department for Public Health and managed by the Kentucky Injury Prevention and Research Center (KIPRC), a unit of the University of Kentucky’s College of Public Health. All trauma centers designated by the Commissioner of Public Health in the Kentucky Trauma Care System maintain trauma registries that are compatible with the National Trauma Data Bank (NTDB) standards established in the National Trauma Data Standard Data Dictionary. The trauma centers upload their trauma data electronically at least quarterly to the KTR. Clinical Data Management, Inc. (CDM) is the vendor that manages the downloading and compilation of data from participating trauma centers, including unverified facilities that report to the registry, and supplies the data to the Kentucky Injury Prevention and Research Center.

With support from the National Highway Traffic Safety Administration through the Kentucky Transportation Cabinet, KIPRC analyzes the statewide trauma registry data and provides a detailed profile of the traumatic injuries treated in the state’s trauma facilities.

Objectives

• List the components essential to a trauma registry
• Identify the trauma registry population
• Describe various standard coding systems and scoring methodologies as it applies to the trauma population

n/a

1. Definition of TBI should include one of the following
   • Direct blow to the head or acceleration/deceleration mode of injury
   • Any head related injury (facial #s, mandible #, broken nose)
   • Significant mechanism (pedestrian vs car, bicycle struck or collision, RTC high speed – rollover, ejection, fall from height > 1m, thrown, head trampled on)
   • Patient has other major trauma injuries
   • Decreasing level of conscious at any time
   • Assault
   • Vague or no recollection of events pre or post injury
   • Active symptoms of concussion such as headache, blurred vision, sensitivity to light or noise, drowsiness, balance problems, nausea/vomiting, poor concentration, fatigue, poor sleep

2. **Discharge home criteria
   • No ongoing clinical indication for prolonged observation e.g no abnormal behaviour, severe post-concussive symptoms, no drugs and/or alcohol intoxication.
   • GCS 15/15
   • if has been tested A-WPTS 18/18
   • Responsible person at home
   • Patient or responsible person understands head injury instructions (provide printout MIDAS document 65632)

3. During assessment
   • Treat symptoms, hydrate and encourage rest and sleep between assessments

4. Referral to Concussion Clinic
   • Attach large patient sticker and patient’s ACC number to concussion clinic form (ACC883)
   • Sign and date form
   • Print clinical notes from EDIS
   • Email ACC883 form, clinical notes and Rivermead symptom evaluation to This email address is being protected from spambots. You need JavaScript enabled to view it.

5. Patients admitted to a ward prior to their concussion evaluation (eg for other significant injuries or illnesses)
   • These should have their assessment as an inpatient. Please document the need for this in patient’s notes and if possible let the admitting team know.

Background: In majority of the low- and middle-income countries (LMICs), the societal cost of injuries are alarming. The severity and magnitude of the road traffic injuries (RTI) in India are not estimated accurately due to the lack of availability of data. The data are limited on the aspects such as demographics, cause, severity of injury, processes of care, and the final outcome of injuries. This study aimed to determine the feasibility of setting up a sustainable trauma registry in Odisha, India, and to determine the demographics, mechanism, severity, and outcomes of injury reported to the facilities/hospital.

Materials and Methods: A prospective observational study was conducted at Srirama Chandra Bhanja Medical College and Hospital (SCB-MCH), Cuttack, India. Injured patients who reported/admitted to the emergency department were observed, and data were collected by using a minimum data set (MDS) developed by the World Health Organization (WHO). Data were collected for a period of one month in June 2015. Observations were collected on 20 variables. The completeness of data collection ranged from 60% (19 variables) to 70% (23 variables) out of total 33 variables.

Results: This study uses 145 cases of injury reported in SCB-MCH. Out of the total reported population at the trauma registry, about 21% were females. Nearly 45% of the injury occurred on road/street. RTI accounted for 36.6% of injury. Out of the total admitted cases, 2.8% died in the emergency department, 11% were discharged to home, and 7.6% left against medical advice. Majority of the respondents have reported single injuries (77%). Head injuries were more common and severe among majority of the reported cases (44.1%), followed by neck injury (28.3%) and chest (15.9%).

Conclusions: This study indicates the challenges in obtaining complete data on injury. Data were missing in terms of admission, discharge, and Glasgow Comma Scale (GCS) among the studied population. This study suggests that individual GCS scoring should be done instead of total GCS scoring in each trauma patient. By collection and storage of adequate data, better policy decisions can be implemented, which will minimize and prevent trauma cases and maximize the utilization of the available resources.

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.

This document, the North Carolina Trauma Registry (NCTR) Data Dictionary, was created using the data dictionary published by the National Trauma Registry of the American College of Surgeons (NTRACS), with modifications specific to the North Carolina Trauma Registry. It is to be used in lieu of the NTRACS data.

It provides a brief summary of every data point used in North Carolina, and notes where there are custom options standard throughout the State. It does not cover those data items that are customized or by each site specifically and not used statewide.

Some data points are not downloaded to the State, i.e., the Central Data Collection Agency. These datapoints are noted with a "d" in the Download Scenario column. Therefore, the statewide registry does not include these data points, although each individual hospital has them.

The column labeled Download Scenario contains information on whether datapoints are to be downloaded to the Central Data Collection Agency (the State) and whether datapoints are sent to the National Trauma Data Bank (NTDB). This column contains one of three values:

• d: This variable is not to be downloaded to the State and is not sent to NTDB
• s: This variable is to be downloaded to the State, but the data are not sent to NTDB
• s,n: This variable is to be downloaded to the State, and may be forwarded to the NTDB.

For the NC Custom Data Points, field type and size information have been included in the Definitions column. The field types are character ( C ), numeric ( N ), and date ( D ) and logic (L). Numeric variables can have decimal places. A numeric variable with a size of 4 with no decimal places would be representative as N4.0. A numeric variable with a size of 4 and 2 decimal places would be represented as N4.2.

The column labeled Datapoint History describes the history of changes to each datapoint and/or discussion, issues, or notes regarding the datapoint. Each change or comment is dated. This column was added in the Jan 2001 version of this data dictionary.