Deconess; Trauma PI Plan

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.