Evidence for quality indicators to evaluate adult trauma care: a systematic review

A prospective evaluation of missed injuries in trauma patients, before and after formalising the trauma tertiary survey

Objective

This study prospectively evaluated in-hospital and postdischarge missed injury rates in admitted trauma patients, before and after the formalisation of a trauma tertiary survey (TTS) procedure.

Methods

Prospective before-and-after cohort study. TTS were formalised in a single regional level II trauma hospital in November 2009. All multitrauma patients admitted between March–October 2009 (preformalisation of TTS) and December 2009–September 2010 (post-) were assessed for missed injury, classified into three types: Type I, in-hospital, (injury missed at initial assessment, detected within 24 h); Type II, in-hospital (detected in hospital after 24 h, missed at initial assessment and by TTS); Type III, postdischarge (detected after hospital discharge). Secondary outcome measures included TTS performance rates and functional outcomes at 1 and 6 months.

Results

A total of 487 trauma patients were included (pre-: n = 235; post-: n = 252). In-hospital missed injury rate (Types I and II combined) was similar for both groups (3.8 vs. 4.8 %, P = 0.61), as were postdischarge missed injury rates (Type III) at 1 month (13.7 vs. 11.5 %, P = 0.43), and 6 months (3.8 vs. 3.3 %, P = 0.84) after discharge. TTS performance was substantially higher in the post-group (27 vs. 42 %, P < 0.001). Functional outcomes for both cohorts were similar at 1 and 6 months follow-up.

Conclusions

This is the first study to evaluate missed injury rates after hospital discharge and demonstrated cumulative missed injury rates >15 %. Some of these injuries were clinically relevant. Although TTS performance was significantly improved by formalising the process (from 27 to 42 %), this did not decrease missed injury rates.

Implementation of a nationwide trauma network for the care of severely injured patients

BACKGROUND

Regional differences in the care of severely injured patients remain problematic in industrial countries.

METHODS

In 2006, the German Society for Trauma Surgery initiated the foundation of regional networks between trauma centers in a TraumaNetwork (TNW). The TNW consisted of five major elements as follows: (a) a whitebook on the treatment of severely injured patients; (b) evidence-based guidelines (S3); (c) local audits; (d) contracts of interhospital cooperation among all participating hospitals; and (e) TraumaRegister documentation. TNW hospitals are classified according to local audit results as supraregional (STC), regional (RTC), or local (LTC) trauma centers by criteria concerning staff, equipment, admission capacity, and responsibility.

RESULTS

Five hundred four German trauma centers (TCs) were certified by the end of December 2012. By then, 37 regional TNWs, with a mean of 13.6 TCs, were established, covering approximately 80% of the country's territory. Of the hospitals, 92 were acknowledged as STCs, 210 as RTCs, and 202 as LTCs.In 2012, 19,124 patients were documented by the certified TCs. Fifty-seven percent of the patients were treated in STCs, 34% in RTCs, and 9% in LTCs. The mean (SD) Injury Severity Score (ISS) was highest in STCs (21 [13]), compared with 18 (12) in RTCs and 16 (10) in LTCs. There were differences in expected mortality (based on Revised Injury Severity Classification) according to the differences in the severity of trauma among the different categories, but in all types, the expected mortality was significantly higher than the observed mortality (differences in STCs, 1.8%; RTCs, 1.4%; LTCs, 2.0%).

CONCLUSION

According to our findings, it is possible to successfully structure and standardize the care of severely injured patients in a nationwide trauma system. Better outcomes than expected were observed in all categories of TNW hospitals.

LEVEL OF EVIDENCE

Epidemiologic study, level III. Therapeutic/care management study, level IV.

Development and evaluation of evidence-informed quality indicators for adult injury care

OBJECTIVE

To develop and evaluate evidence-informed quality indicators of adult injury care.

BACKGROUND

Injury is a leading cause of morbidity and mortality, but there is a lack of consensus regarding how to evaluate injury care.

METHODS

Using a modification of the RAND/UCLA Appropriateness Methodology, a panel of 19 injury and quality of care experts serially rated and revised quality indicators identified from a systematic review of the literature and international audit of trauma center quality improvement practices. The quality indicators developed by the panel were sent to 133 verified trauma centers in the United States, Canada, Australia, and New Zealand for evaluation.

RESULTS

A total of 84 quality indicators were rated and revised by the expert panel over 4 rounds of review producing 31 quality indicators of structure (n=5), process (n=21), and outcome (n=5), designed to assess the safety (n=8), effectiveness (n=17), efficiency (n=6), timeliness (n=16), equity (n=2), and patient-centeredness (n=1) of injury care spanning prehospital (n=8), hospital (n=19), and posthospital (n=2) care and secondary injury prevention (n=1). A total of 101 trauma centers (76% response rate) rated the indicators (1=strong disagreement, 9=strong agreement) as targeting important health improvements (median score 9, interquartile range [IQR] 8-9), easy to interpret (median score 8, IQR 8-9), easy to implement (median score 8, IQR 7-8), and globally good indicators (median score 8, IQR 8-9).

CONCLUSIONS

Thirty-one evidence-informed quality indicators of adult injury care were developed, shown to have content validity, and can be used as performance measures to guide injury care quality improvement practices.

A comparison of quality improvement practices at adult and pediatric trauma centers*

OBJECTIVES

Quality assurance practices are structured performance improvement and patient safety processes designed to continuously monitor, evaluate, and improve the performance of a trauma program. These practices are integral in the provision of quality injury care, and yet no comprehensive description of existing quality improvement practices used by pediatric trauma centers is available. Therefore, we compared the quality improvement programs used in adult and pediatric trauma centers by performing a reanalysis of our recent survey of trauma quality improvement practices in Canada, United States, Australia, and New Zealand.

DESIGN

Prospective observational study.

SETTING

Pediatric and adult trauma centers in United States, Canada, and Australasia.

PATIENTS

None.

INTERVENTIONS

None.

MEASUREMENTS

We surveyed 184 trauma centers verified by professional trauma organizations in the United States, Canada, and Australasia regarding their quality improvement programs. Centers were classified according to population served (adult, adult and pediatric, or pediatric patients), and quality improvement programs were compared using descriptive statistics.

RESULTS

Most of the trauma centers reported engagement in quality improvement activities. Adult centers devoted a larger percentage of their quality indicators to the measurement of safety (adult 50% vs adult and pediatric 53% vs pediatric 38%, p < 0.001), whereas pediatric centers placed a greater emphasis on the timeliness of care (20% vs 24% vs 30%, p < 0.001). Few centers used quality indicators to measure the patient-centered nature of care, long-term outcomes, or secondary injury prevention.

CONCLUSIONS

Opportunities for the improvement of pediatric quality improvement programs exist including a need to determine the optimal structure for trauma quality improvement, develop patient-centered quality indicators of injury care, measure long-term outcomes, and create measures of secondary injury prevention.

Measuring quality of care: considering measurement frameworks and needs assessment to guide quality indicator development

OBJECTIVE

In this article, we describe one approach for evaluating the value of developing quality indicators (QIs).

STUDY DESIGN AND SETTING

We focus on describing how to develop a conceptual measurement framework and how to evaluate the need to develop QIs. A recent process to develop QIs for injury care is used for illustration.

RESULTS

Key steps to perform before developing QIs include creating a conceptual measurement framework, determining stakeholder perspectives, and performing a QI needs assessment. QI development is likely to be most beneficial for medical problems for which quality measures have not been previously developed or are inadequate and that have a large burden of illness to justify quality measurement and improvement efforts, are characterized by variable or substandard care such that opportunities for improvement exist, and have evidence that improving quality of care will improve patient health.

CONCLUSION

By developing a conceptual measurement framework and performing a QI needs assessment, developers and users of QIs can target their efforts.

Evaluation of emergency department performance - a systematic review on recommended performance and quality-in-care measures

BACKGROUND

Evaluation of emergency department (ED) performance remains a difficult task due to the lack of consensus on performance measures that reflects high quality, efficiency, and sustainability.

AIM

To describe, map, and critically evaluate which performance measures that the published literature regard as being most relevant in assessing overall ED performance.

METHODS

Following the PRISMA guidelines, a systematic literature review of review articles reporting accentuated ED performance measures was conducted in the databases of PubMed, Cochrane Library, and Web of Science. Study eligibility criteria includes: 1) the main purpose was to discuss, analyse, or promote performance measures best reflecting ED performance, 2) the article was a review article, and 3) the article reported macro-level performance measures, thus reflecting an overall departmental performance level.

RESULTS

A number of articles addresses this study's objective (n = 14 of 46 unique hits). Time intervals and patient-related measures were dominant in the identified performance measures in review articles from US, UK, Sweden and Canada. Length of stay (LOS), time between patient arrival to initial clinical assessment, and time between patient arrivals to admission were highlighted by the majority of articles. Concurrently, "patients left without being seen" (LWBS), unplanned re-attendance within a maximum of 72 hours, mortality/morbidity, and number of unintended incidents were the most highlighted performance measures that related directly to the patient. Performance measures related to employees were only stated in two of the 14 included articles.

CONCLUSIONS

A total of 55 ED performance measures were identified. ED time intervals were the most recommended performance measures followed by patient centeredness and safety performance measures. ED employee related performance measures were rarely mentioned in the investigated literature. The study's results allow for advancement towards improved performance measurement and standardised assessment across EDs.

Trauma center performance indicators for nonfatal outcomes: a scoping review of the literature

BACKGROUND

According to Donabedian's framework, outcomes covering the following six domains should be used to evaluate health care quality: death, adverse events, readmissions to hospital, resource use, quality of life, and ability to function in daily activities. The objective of this study was to identify the nonfatal outcomes that have been used to evaluate the performance of trauma hospitals. Secondary objectives were to describe definitions and methodological quality.

METHODS

We performed a scoping literature review of studies using at least one nonfatal outcome to evaluate the performance of acute care hospitals for the treatment of general trauma populations. We searched MEDLINE, EMBASE, Cochrane central, CINAHL, BIOSIS, TRIP and ProQuest databases. Methodological quality was evaluated using elements of the STROBE statement and the Downs and Black tool.

RESULTS

Of 14,521 citations, 40 were eligible for inclusion. We identified 14 nonfatal outcomes as follows: (i) adverse events including complications (used in 35 evaluations), missed injuries (n = 4), reintubation (n = 2), unplanned intensive care unit admissions (n = 2), and unplanned surgeries (n = 4); (ii) resource use including hospital (n = 19), intensive care unit (n = 15), and ventilator (n = 4) length of stay, inappropriate hospital stay (n = 1), and potentially unnecessary care (n = 1); (iii) hospital readmissions (n = 4); and (iv) ability to function in daily activities including functional capacity (n = 2), and discharge destination (n = 3). No measures of quality of life were identified. There was high heterogeneity in the definitions used. Only 18% of studies had high methodological quality.

CONCLUSION

Among recommended domains of nonfatal outcomes, adverse events and resource use were frequently used to evaluate trauma care, readmissions and function in daily activities were rarely used, and quality of life was never used. In addition, definitions of nonfatal outcomes were variable, and methodological quality was low. There is a need to develop valid and reliable performance indicators based on each domain of Donabedian's framework to evaluate trauma care.

Capture-mark-recapture to estimate the number of missed articles for systematic reviews in surgery

BACKGROUND

Systematic reviews are an important knowledge synthesis tool, but with new literature available each day, reviewers must balance identifying all relevant literature against timely synthesis.

METHODS

This study tested capture-mark-recapture (CMR), an ecology-based technique, to estimate the total number of articles in the literature identified in a systematic review of adult trauma care quality indicators.

RESULTS

The systematic review included 40 articles identified from online searches and citation references. The CMR model suggested that 3 (95% confidence interval [CI]: 0 to 6) articles were missed and the database search provided 93% (one-sided 95% CI: ≥83%) of known articles for inclusion in the systematic review. The search order used for identifying the articles was optimal among the 24 that could have been used.

CONCLUSIONS

The CMR technique can be used in systematic reviews in surgery to estimate the closeness to capturing the total body of literature for a specific topic.

A qualitative analysis of a consensus process to develop quality indicators of injury care

Background

Consensus methodologies are often used to create evidence-based measures of healthcare quality because they incorporate both available evidence and expert opinion to fill gaps in the knowledge base. However, there are limited studies of the key domains that are considered during panel discussion when developing quality indicators.

Methods

We performed a qualitative content analysis of the discussions from a two-day international workshop of injury control and quality-of-care experts (19 panel members) convened to create a standardized set of quality indicators for injury care. The workshop utilized a modified RAND/UCLA Appropriateness method. Workshop proceedings were recorded and transcribed verbatim. We used constant comparative analysis to analyze the transcripts of the workshop to identify key themes.

Results

We identified four themes in the selection, development, and implementation of standardized quality indicators: specifying a clear purpose and goal(s) for the indicators to ensure relevant data elements were included, and that indicators could be used for system-wide benchmarking and improving patient outcomes; incorporating evidence, expertise, and patient perspectives to identify important clinical problems and potential measurement challenges; considering context and variations between centers in the health system that could influence either the relevance or application of an indicator; and contemplating data collection and management issues, including availability of existing data sources, quality of data, timeliness of data abstraction, and the potential role for primary data collection.

Conclusion

Our study provides a description of the key themes of discussion among a panel of clinical, managerial, and data experts developing quality indicators. Consideration of these themes could help shape deliberation of future panels convened to develop quality indicators.

Evaluating trauma center process performance in an integrated trauma system with registry data

BACKGROUND

The evaluation of trauma center performance implies the use of indicators that evaluate clinical processes. Despite the availability of routinely collected clinical data in most trauma systems, quality improvement efforts are often limited to hospital-based audit of adverse patient outcomes.

OBJECTIVE

To identify and evaluate a series of process performance indicators (PPI) that can be calculated using routinely collected trauma registry data.

MATERIALS AND METHODS

PPI were identified using a review of published literature, trauma system documentation, and expert consensus. Data from the 59 trauma centers of the Quebec trauma system (1999, 2006; N = 99,444) were used to calculate estimates of conformity to each PPI for each trauma center. Outliers were identified by comparing each center to the global mean. PPI were evaluated in terms of discrimination (between-center variance), construct validity (correlation with designation level and patient volume), and forecasting (correlation over time).

RESULTS

Fifteen PPI were retained. Global proportions of conformity ranged between 6% for reduction of a major dislocation within 1 h and 97% for therapeutic laparotomy. Between-center variance was statistically significant for 13 PPI. Five PPI were significantly associated with designation level, 7 were associated with volume, and 11 were correlated over time.

CONCLUSION

In our trauma system, results suggest that a series of 15 PPI supported by literature review or expert opinion can be calculated using routinely collected trauma registry data. We have provided evidence of their discrimination, construct validity, and forecasting properties. The between-center variance observed in this study highlights the importance of evaluating process performance in integrated trauma systems.

Evaluating trauma center structural performance: The experience of a Canadian provincial trauma system

BACKGROUND

Indicators of structure, process, and outcome are required to evaluate the performance of trauma centers to improve the quality and efficiency of care. While periodic external accreditation visits are part of most trauma systems, a quantitative indicator of structural performance has yet to be proposed. The objective of this study was to develop and validate a trauma center structural performance indicator using accreditation report data.

MATERIALS AND METHODS

Analyses were based on accreditation reports completed during on-site visits in the Quebec trauma system (1994-2005). Qualitative report data was retrospectively transposed onto an evaluation grid and the weighted average of grid items was used to quantify performance. The indicator of structural performance was evaluated in terms of test-retest reliability (kappa statistic), discrimination between centers (coefficient of variation), content validity (correlation with accreditation decision, designation level, and patient volume) and forecasting (correlation between visits performed in 1994-1999 and 1998-2005).

RESULTS

Kappa statistics were >0.8 for 66 of the 73 (90%) grid items. Mean structural performance score over 59 trauma centers was 47.4 (95% CI: 43.6-51.1). Two centers were flagged as outliers and the coefficient of variation was 31.2% (95% CI: 25.5% to 37.6%), showing good discrimination. Correlation coefficients of associations with accreditation decision, designation level, and volume were all statistically significant (r = 0.61, -0.40, and 0.24, respectively). No correlation was observed over time (r = 0.03).

CONCLUSION

This study demonstrates the feasibility of quantifying trauma center structural performance using accreditation reports. The proposed performance indicator shows good test-retest reliability, between-center discrimination, and construct validity. The observed variability in structural performance across centers and over-time underlines the importance of evaluating structural performance in trauma systems at regular intervals to drive quality improvement efforts.

Developing process guidelines for trauma care in the Netherlands for severely injured patients: results from a Delphi study

BACKGROUND

In organised trauma systems the process of care is the key to quality. Nevertheless, the optimal process of trauma care remains unclear due to lack of or inconclusive evidence. Because monitoring and improving the performance of a trauma system is complex, this study aimed to develop consensus-based process guidelines for trauma care in the Netherlands for severely injured patients.

METHODS

A five-round Delphi study was conducted with 141 participants that represent all professions involved in trauma care. Sensitivity analyses were carried out to evaluate whether consensus extended across all professions and to detect possible bias.

RESULTS

Consensus was reached on 21 guidelines within 4 categories: timeliness, actions, competent teams and interdisciplinary process. Timeliness guidelines set specific critical limits and definitions for 10 time intervals in the time period from an emergency call until the patient leaves the trauma room. Action guidelines reflect aspects of appropriate care and strongly rely on the international Advanced Trauma Life Support principles. Competence guidelines include flow charts to assess the competence of prehospital and emergency department teams. Essential to competent teams are education and experience of all team members. The interdisciplinary process guideline focuses on cooperation, communication and feedback within and between all professions involved. Consensus was extended across all professions and no bias was detected.

CONCLUSIONS

In this Delphi study, a large expert panel agreed on a set of guidelines describing the optimal process of care for severely injured trauma patients in the Netherlands. In addition to time intervals and appropriate actions, these guidelines emphasise the importance of team competence and interdisciplinary processes in trauma care. The guidelines can be seen as a description of a best practice and a new field standard in the Netherlands. The next step is to implement the guidelines and monitor the performance of the Dutch trauma system based on the guidelines.

Feasibility and early outcomes of intensivist-led critical care after major trauma in the Korean ICU

PURPOSE

Substantial evidence supports the benefits of an intensivist model of critical care delivery. However, currently, this mode of critical care delivery has not been widely adopted in Korea. We hypothesized that intensivist-led critical care is feasible and would improve ICU mortality after major trauma.

MATERIALS AND METHODS

A trauma registry from May 2009 to April 2011 was reviewed retrospectively. We evaluated the relationship between modes of ICU care (open vs. intensivist) and in-hospital mortality following severe injury [Injury Severity Score (ISS)>15]. An intensivist-model was defined as ICU care delivered by a board-certified physician who had no other clinical responsibilities outside the ICU and who is primarily available to the critically ill or injured patients. ISS and Revised Trauma Score were used as measure of injury severity. The Trauma and Injury Severity Score methodology was used to calculate each individual patient's probability of survival.

RESULTS

Of the 251 patients, 57 patients were treated by an intensivist [intensivist group (IG)] while 194 patients were not [non-intensivist group (NIG)]. The ISS of IG was significantly higher than that for NIG (26.5 vs. 22.3, p=0.023). The hospital mortality rate for IG was significantly lower than that for NIG (15.8% and 27.8%, p<0.001).

CONCLUSION

The intensivist model of critical care is feasible, and there is room for improvement in the care of major trauma patients. Although trauma systems take time to mature, future studies are needed to evaluate the best model of critical care delivery for severely injured patients in Korea.

Developing a patient and family-centred approach for measuring the quality of injury care: a study protocol

Background

Quality indicators (QI) are used in health care to measure quality of service and performance improvement. Health care professionals and organizations caring for patients with injuries need information regarding the quality of care provided and the outcomes experienced in order to target improvement efforts. However, very little is known about the quality of injury care provided to individual patients and populations and even less about patients’ perspectives on quality of care. The absence of QIs that incorporate patient or family preferences, needs or values has been identified as an important gap in the science and practice of injury quality improvement. The primary objective of this research protocol is to develop and evaluate the first set of patient and family-centred QIs of injury care for critically injured patients

Methods/design

This mixed methods study is comprised of three Sub-Studies. Sub-Study A will utilize focus group methodology to describe the preferences, needs and values of critically injured patients and their family members regarding the quality of health care delivered. Qualitative content analysis of the transcripts will begin after the first completed focus group and will draw on grounded theory using a process of open, axial and selective coding. A panel of stakeholders will be assembled during Sub-Study B to review the themes identified from the focus groups and develop a catalogue of potential patient and family-centred QIs of injury care using the RAND/UCLA Appropriateness Method (RAM). The QIs developed by the stakeholder panel will be pilot tested in Sub-Study C using surveys of patients and their family members to determine construct validity, intra-rater reliability and clinical sensibility.

Discussion

Measuring the quality of injury care is but a first step towards improving patient outcomes. This research will develop the first set of patient and family-centred QIs of injury care. To improve patient care, we need accessible, reliable indicators of quality that are important to patients, and that can then be used to establish quality of care benchmarks, to flag potential problems or successes, follow trends over time and identify disparities across organizations, communities, populations and regions.

Preventable mortality evaluation in the ICU

Mortality is the most widely measured outcome parameter. Improvement of this outcome parameter in critical care is nowadays expected not to come from new technologies or treatment, but from delivering the right care at the right moment in a safe way. The measurement of mortality as an outcome parameter confronts us with a problem in providing follow-up to the results. Especially when proven structure and process interventions are applied already, the cause of a suboptimal performance cannot be deduced easily. One possibility is to evaluate the causes of death and to judge preventability. In this article we explore the opportunities and difficulties of a tool to evaluate preventable mortality in the ICU.

The effect of tertiary surveys on missed injuries in trauma: a systematic review

Background

Trauma tertiary surveys (TTS) are advocated to reduce the rate of missed injuries in hospitalized trauma patients. Moreover, the missed injury rate can be a quality indicator of trauma care performance. Current variation of the definition of missed injury restricts interpretation of the effect of the TTS and limits the use of missed injury for benchmarking. Only a few studies have specifically assessed the effect of the TTS on missed injury. We aimed to systematically appraise these studies using outcomes of two common definitions of missed injury rates and long-term health outcomes.

Methods

A systematic review was performed. An electronic search (without language or publication restrictions) of the Cochrane Library, Medline and Ovid was used to identify studies assessing TTS with short-term measures of missed injuries and long-term health outcomes. ‘Missed injury’ was defined as either: Type I) any injury missed at primary and secondary survey and detected by the TTS; or Type II) any injury missed at primary and secondary survey and missed by the TTS, detected during hospital stay. Two authors independently selected studies. Risk of bias for observational studies was assessed using the Newcastle-Ottawa scale.

Results

Ten observational studies met our inclusion criteria. None was randomized and none reported long-term health outcomes. Their risk of bias varied considerably. Nine studies assessed Type I missed injury and found an overall rate of 4.3%. A single study reported Type II missed injury with a rate of 1.5%. Three studies reported outcome data on missed injuries for both control and intervention cohorts, with two reporting an increase in Type I missed injuries (3% vs. 7%, P<0.01), and one a decrease in Type II missed injuries (2.4% vs. 1.5%, P=0.01).

Conclusions

Overall Type I and Type II missed injury rates were 4.3% and 1.5%. Routine TTS performance increased Type I and reduced Type II missed injuries. However, evidence is sub-optimal: few observational studies, non-uniform outcome definitions and moderate risk of bias. Future studies should address these issues to allow for the use of missed injury rate as a quality indicator for trauma care performance and benchmarking.

Complication rates as a trauma care performance indicator: a systematic review

Introduction

Information on complication rates is essential to trauma quality improvement efforts. However, it is unclear which complications are the most clinically relevant. The objective of this study was to evaluate whether there is consensus on the complications that should be used to evaluate the performance of acute care trauma hospitals.

Methods

We searched the Medline, EMBASE, Cochrane Central, CINAHL, BIOSIS, TRIP and ProQuest databases and included studies using at least one nonfatal outcome to evaluate the performance of acute care trauma hospitals. Data were extracted in duplicate using a piloted electronic data abstraction form. Consensus was considered to be reached if a specific complication was used in ≥ 70% of studies (strong recommendation) or in ≥ 50% of studies (weak recommendation).

Results

Of 14,521 citations identified, 22 were eligible for inclusion. We observed important heterogeneity in the complications used to evaluate trauma care. Seventy-nine specific complications were identified but none were used in ≥ 70% of studies and only three (pulmonary embolism, deep vein thrombosis, and pneumonia) were used in ≥ 50% of studies. Only one study provided evidence for the clinical relevance of complications used and only five studies (23%) were considered of high methodological quality.

Conclusion

Based on the results of this review, we can make a weak recommendation on three complications that should be used to evaluate acute care trauma hospitals; pulmonary embolism, deep vein thrombosis, and pneumonia. However, considering the observed disparity in definitions, the lack of clinical justification for the complications used, and the low methodological quality of studies, further research is needed to develop a valid and reliable performance indicator based on complications that can be used to improve the quality and efficiency of trauma care.

Trauma center quality improvement programs in the United States, Canada, and Australasia

OBJECTIVE

To compare quality improvement (QI) programs of trauma centers in 4 high-income countries.

BACKGROUND

Injury is a leading cause of morbidity and mortality in countries around the world, but patient outcomes vary among countries with similar systems of trauma care.

METHODS

We surveyed medical directors and program managers from 330 trauma centers verified by professional trauma organizations in the United States (n = 263), Canada (n = 46), and Australasia (Australia, n = 18; New Zealand, n = 3) regarding their QI programs. Quality indicators were requested from all centers that measured quality of care. Follow-up interviews were performed with 75 centers purposively sampled across 6 baseline criteria.

RESULTS

A total of 251 centers (76% response rate) responded to the survey, with a similar distribution across countries. Trauma centers in the United States were more likely than those in Canada and Australasia to report measuring quality indicators (100% vs 94% vs 93%, P = 0.008), using report cards (53% vs 33% vs 31%, P = 0.033) and benchmarking (81% vs 61% vs 69%, P = 0.019). Centers in all 3 regions primarily used hospital process and outcome measures designed to establish whether care was safe (98% vs 97% vs 75%, P = 0.008), effective (97% vs 97% vs 92% P = 0.399), timely (88% vs 100% vs 92%, P = 0.055), and efficient (95% vs 100% vs 83%, P = 0.082). QI programs were largely local in nature, used different criteria to identify patients under QI purview, and employed diverse quality indicators and improvement strategies. Few centers evaluated the effectiveness of their QI program.

CONCLUSIONS

This study provides the first international comparison of trauma center QI programs and demonstrates broad implementation in verified trauma centers in the United States, Canada, and Australasia. Significant variation exists in how trauma centers perform QI activities. Opportunities exist for improving and standardizing QI processes.

Quality indicators used by trauma centers for performance measurement

BACKGROUND

To describe the quality indicators (QIs) that trauma centers use for quality measurement and performance improvement. Measuring and reporting quality of care is a critical step to improve the quality of care. QIs compare actual trauma care against ideal criteria and identify patients in whom care may have been suboptimal and should be further reviewed.

METHODS

Three hundred thirty verified trauma centers in the United States, Canada, Australia, and New Zealand had their websites reviewed and leadership surveyed regarding QI use. The indicators identified were classified according to definition specifications, phase of care, Institute of Medicine aims, and contents.

RESULTS

Two hundred fifty-one centers responded to the survey (76%) and the majority (97%) indicated that they use QIs. We obtained 10,587 QIs from 262 centers (survey responses and website review) of which 1,102 were unique indicators. The QIs primarily assessed the safety (49%), effectiveness (32%), efficiency (27%), and timeliness (22%) of hospital processes (64%) and outcomes (24%). The majority of indicators were used by a small number of centers (551 of 1,102 unique indicators used by single centers).

CONCLUSION

Our study provides the first description of the QIs used by verified trauma centers in four high-income countries with similar systems of trauma care. The majority of trauma centers measure QIs designed to examine the safety, effectiveness, efficiency, and timeliness of hospital processes and outcomes. Opportunities exist to standardize existing QIs to allow broader implementation and develop new QIs to examine patient-centered care and equality of care.

Trauma center volume and quality improvement programs

BACKGROUND

Growing evidence suggests that for many treatments, a relationship exists between provider volume and patient outcomes. This relationship is less clear in injury management. We sought to evaluate whether a relationship exists between trauma center volume and the nature of quality improvement (QI) programs.

METHODS

This is a survey of 154 verified adult trauma centers in the United States, Canada, Australia, and New Zealand (76% response rate) regarding their QI programs. Centers were classified according to American College of Surgeons annual volume requirements for a Level I center (low volume vs. high volume) and QI programs compared.

RESULTS

All participating trauma centers reported using a trauma registry and measuring quality of care. Low-volume centers were more likely than high-volume centers to use quality indicators for evaluating triage and patient flow (18% vs. 13%, p < 0.001), effectiveness of care (33% vs. 30%, p = 0.016), and efficiency of care (29% vs. 23%, p < 0.001). High-volume centers were more likely to use quality indicators for evaluating medical errors and adverse events (30% vs. 36%, p < 0.001) and the use of guidelines/protocols (2% vs. 3%, p = 0.001). Report cards (41% vs. 59%, p = 0.025) and internal benchmarking (79% vs. 91%, p = 0.040) were less frequently reported to be used by low-volume than high-volume centers.

CONCLUSIONS

Both low- and high-volume centers reported being engaged in QI. Small differences in the types of quality indicators used by centers were observed according to volume, with high-volume centers more likely than low-volume centers to use report cards and benchmarking as QI tools.

Verification and regionalization of trauma systems: the impact of these efforts on trauma care in the United States

Efforts to develop trauma systems in the United States followed the publication of the landmark article, "Accidental Death and Disability: The Neglected Disease of Modern Society," by the National Academy of Sciences (1966) and have resulted in the implementation of a system of care for the seriously injured in most states and within the US military. In 2007, Hoyt and Coimbra published an article detailing the history, organization, and future directions of trauma systems within the United States. This article provides an update of the developments that have occurred in trauma systems in system verification and regionalization.

Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol

BACKGROUND

In May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?

METHODS/DESIGN

The study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.

DISCUSSION

At the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.

Indicators of the quality of trauma care and the performance of trauma systems

Background

Valid and reliable measures of trauma system performance are needed to guide improvement activities, benchmarking and public reporting, future investment and research. Traditional measures of in-hospital mortality fail to take into account prehospital and posthospital care, recovery after discharge, and the nature and costs of long-term disability.

Methods

Drawing on recent systematic reviews, an overview was conducted of existing and emerging trauma care performance indicators. Changes in the nature and purpose of indicators were assessed.

Results

Among a large number of existing, mostly locally developed performance indicators, only peer review of deaths has evidence of validity or reliability. The usefulness of the traditional performance measure of in-hospital mortality has been challenged. There is an emerging shift in focus from mortality to non-mortality outcomes, from hospital-based to long-term community-based outcome assessment, and from single measures of trauma centre performance to measures better suited to monitoring the performance of systems of care spanning the entire patient journey. As a result, a new generation of indicators is emerging that are both feasible and potentially more useful for commissioners and payers of population-based services.

Conclusion

A global endeavour is now under way to agree on a set of standardized performance indicators that are meaningful to patients, carers, clinicians, managers and service funders, are likely to contribute to desired outcomes, and are valid, reliable and have a strong evidence base.

The 'off-hour' effect in trauma care: a possible quality indicator with appealing characteristics

A recent paper has drawn attention to the paucity of widely accepted quality indicators for trauma care. At the same time, several studies have measured whether mortality of trauma patients changes between normal working time and other parts of the day/week, i.e. the so-called 'off-hour' or 'weekend' effect. This measure has the characteristics to become an accepted quality indicator because it combines the advantages of both outcome and process indicators. As an outcome indicator it would not need validation, a procedure particularly difficult in trauma care where gathering scientific evidence is more difficult than in other disciplines. As a process indicator it would provide indications about where to intervene to improve quality.