Plastic Surgery Service for incision, drainage and removal of the foreign body of the left hand. The patient was ultimat
M&M / Peer Review
Trauma Medical Director Course
Michael D. McGonigal MD Director of Trauma Services Regions Hospital, St. Paul MN
P
ERFORMANCE
I
MPROVEMENT &
P
ATIENT
S
AFETY
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Disclosures
Reviewer for the ACS
Opinions expressed are mine alone
I LOVE PI!
Objectives
Recognize the importance of PI to Trauma Center function and verification Review generic PI program design Understand how to deal with common PI program problems Appreciate nuances in PI at Level III centers
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Importance of PI Program
Important to verifying agencies – Typical site survey (I-II)
1 hour facility inspection 5hrs + of PI review
Important to you – Documents the quality of the trauma care that you provide – Especially the care before transfer out at Level III centers – Most common reason for verification visit deficiencies
Performance Improvement Program
What it is – Continuous monitoring of processes and outcomes – Time and data intensive – Vitally important to the existence of your center
What it is not – Easy – Cheap – A guarantee of passing your verification visit
Reviewing trauma activation and consultation criteria with ED physicians
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“Closing The Loop”
Identification – Finding patterns of problems
Dramatic increase in number of admits to non-surgical services
Correction – Providing remediation
Reviewing trauma activation and consultation criteria with ED physicians Educating nonsurgical service chiefs
“Closing The Loop”
Monitoring – Repeat data collection
Monitor non-surgical admits for another quarter
Documentation – Maintain an easily followed audit trail of entire process
Trauma PI Review Patient: MR#: Date: Issue:
xx xxxxxxxx 3-25-10
Readmission to ICU, retained foreign body Discussion: This is a 49 year old male who was admitted to the Trauma Unit on 03-16-10 after falling or jumping out of a car. Injuries included abrasions and lacerations to the left hand, right forearm and scalp. Lacerations were sutured by the TACS Service and the patient was discharged on 03-18-10. One day after discharge, the patient was readmitted to the SICU with report of an intracranial hemorrhage from an outside hospital. A retained foreign body was also noted at the left hand wound. This retained foreign body was associated with a wound infection. Ultimately, the patient was cleared by Neurosurgery but went to the operating room with the Plastic Surgery Service for incision, drainage and removal of the foreign body of the left hand. The patient was ultimately discharged on 03-21-10. The patient has two care issues. His readmission with headache and potential neurologic changes is unavoidable. Outside CT scan was read as containing blood which was not demonstrated on a follow-up study at Regions Hospital. This appears to be a misread and in not an active PI issue. The second issue is foreign body which was retained in the left hand during closure. This is a probable source of infection. While the TACS Service was aware that films had been obtained of the hand, the films were not reviewed by the surgeon closing the hand wound. Readmission is appropriate given the pattern of presentation. Missed foreign body reflects failure of the Trauma Service to review imaging prior to closure of the wound. Dr. McGonigal was the attending surgeon. Determination: 1. Delayed presentation of intracranial hemorrhage – not present 2. Delayed diagnosis of hand foreign body with infection – preventable with readmission and additional surgical procedure required. Care processes not appropriate. Action: Drs. McGonigal, X, Y, Z, Q and W were present for discussion.
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Provides risk-adjusted benchmarking to track patient outcomes and improve patient care – – – – – –
Utilizes NTDB data Registrar training and conferences External data audits Risk adjusted using other similar trauma centers Shares best practices Required for ALL trauma programs Jan 2017
Functions of the TMD
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Specific Pointers
PI personnel & staffing needs to make sense for your program!
Specific Pointers
Work closely with your TPM – Don’t abandon them!
Make sure all possible routes into the hospital are covered – How to deal with admits to nonsurgical services – Direct admits
Specific Pointers
Keep up on required meeting attendance
Attend to all PI in a timely manner
Maintained detailed documentation of all discussions, in writing – Direct – Minutes – Email?
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Specific Pointers
Organize, organize, organize – Use your trauma registry or other software
Patient folders System issue folders Open item list
– Keep a list of your successes
Specific Pointers
Mind your registrars – 1 FTE per 500-750 trauma registry admits – Don’t underestimate TQIP
Don’t forget trauma activation patients who are discharged from the ED!
Specific Pointers
Organize your PI well for your site visit – – – – –
Patient folders System issue folders Flag key areas of your medical records Assign one EMR expert to each reviewer Test everything that is not made of paper
– Don’t even try to cheat!
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Final Pointers
Design a solid PI program foundation
Take the initiative to make the process meaningful
Pay as much attention to PI as you do to your clinical responsibilities
Find creative solutions to tough problems and document them well
Document everything, and document it in an easy to follow format.
There seems to be quite a bit of variability of orthopedic trauma transfers from my Level III ED How can you investigate and correct this problem?
Case 2
You are the director of a trauma hospital that is 4 months away from its first Level II verification visit. For the past two months, you and your nurse coordinator have been feverishly crafting your new PI process. You are both very happy with the result. Should you go forward with the site visit, or delay for several more months while the PI program “matures?”
Case 3
You use a multi-tiered trauma activation system. You note that 40% of your second level activations are discharged home from the ED How can you investigate and remedy this?
