Hospital staffing shortages are making it hard for many trauma program leaders to fulfill key responsibilities, including performance improvement (PI) activities.
That is one of the major findings of the recent “Top Concerns in Trauma” Survey that Philips Trauma Center Consulting Services conducted with Trauma System News.
The goal of our survey was to identify the issues that trauma program leaders are most concerned about as they prepare for 2022. So far, nearly 300 trauma professionals have taken the survey. Overall, respondents paint a picture of trauma programs that are being squeezed by lack of staff, lack of money and lack of support.
One of the most concerning findings is that PI activities have been curtailed in many centers. Here are a few representative comments:
- “Managers, directors and support staff are getting pulled to the floor to help, which removes us from managing PI processes and tracking of patients in-house. Concerned for how we are going to be able to have quality PI and to be able to adequately show it for virtual surveys.”
- “…our biggest challenge right now is that everyone is tapped out. We can’t get movement on any projects (PI interventions) and move toward the loop closure part of the process because literally nobody has time or mental energy to even think about these issues or creative solutions. We’re just trying to survive at this point.”
- “Any education and PI initiatives through the trauma department have been sidelined for nearly a year, and it is evident through performance.”
Respondents also reported concerns with trauma team morale, trauma program funding and continued delays in the release of the new trauma center standards from the American College of Surgeons (ACS).
I will address all of these issues during a special webinar coming later this fall. (For more details on this upcoming webinar, see below.) In the meantime, I want to look at the challenges that trauma programs are facing with trauma PI.
If you are concerned that your PI efforts are falling behind, the main thing to do right now is take a deep breath and refocus on what is most important. Below, I explain several strategies for streamlining your PI efforts.
But first, two important clarifications:
- The recommendations described below are meant to serve as a temporary solution to a critical need. They should not be considered “standard operating procedures” for a trauma PI program, but an “emergency protocol” for programs facing an acute resource shortage.
- Any changes to your PI plan or processes should be agreed upon by the entire leadership team. TPMs and PI coordinators should involve the trauma medical director in any decisions that significantly impact PI procedures.
1. Revise your PI plan to focus on the “mission critical”
If your trauma program has a formal PI plan, revisit the plan document and take a fresh look at your audit filters. Determine which filters are “mission critical” and which are simply “nice to know” or “nice to follow.” Focus your attention on the mission critical issues and, for the time being, set the rest aside.
Which filters or quality issues are mission critical for a trauma program? In general, the events you must address are:
- Any mortality
- Any delay in care for a hemodynamically unstable patient
- Any readmission
- Any complication, missed injury or other issue that leads to avoidable hospital days, avoidable ICU care or an additional procedure
These events represent a true impact on the patient outcome, so they are a top priority no matter what else is going on in your program.
Refocus your audit filters on these events and issues. For any that arise, perform a full PI workup including conducting a chart review, writing a case summary and referring the case to a higher level of review as appropriate.
For any other PI event — and here I mean issues that resulted in no harm to the patient — I recommend an abbreviated response. Simply note the event within your PI database and close it at primary review. Then move on. Alternatively, note and close the event but tag it in some way for later follow-up. The key is to capture the information so you can understand the scope of the problem without having to intervene immediately.
Here are two examples of how to apply this approach:
- Patient A complains of shoulder pain during the tertiary exam, and it turns out to be a distal clavicle fracture (DCF). Under the “mission critical” framework, this is not a significant finding. It does not extend the patient’s hospital stay or require an additional procedure. Note the missed injury in your documentation and move on.
- Patient B complains of shoulder pain during the tertiary exam, and it turns out to be a displaced DCF that requires surgical fixation. This missed injury is a significant finding that impacts the patient’s outcome, and you need to prevent this problem from happening again. Perform a complete PI workup and refer this event for a higher level of review.
What do I do if we don’t have a PI plan? You can still sharpen the focus of your PI activities. Identify your current process for identifying events and determine which PI issues are mission critical and which are secondary.
How do I get overworked providers to engage in PI? This challenge was noted by several survey respondents. One thing you can do is make PI meetings easier to attend. Create a virtual meeting environment that is compliant with COVID-related restrictions and ACS or state mandates for meeting attendance. Encourage the use of video monitors to improve engagement and participation. Another thing you can do to encourage participation is to limit the number of cases for review to those that require multidisciplinary input around a significant issue or event.
2. Narrow your focus to TQIP areas of concern
If your center participates in the Trauma Quality Improvement Program (TQIP), you should also reassess your approach to monitoring your TQIP cohorts.
Trauma program leaders tend to watch these cohorts very closely, often following every patient who is eligible for inclusion. In the current environment, however, most PI leaders do not have the bandwidth to comb through hundreds of patient records.
Here are two scenarios to help explain this approach:
Say your center is a high outlier on the mortality in isolated hip fracture cohort of TQIP. This is a demonstrated problem area for your program, so it is imperative that you keep it under the microscope. Continue to review all patients in this cohort, preferably in real time as they move through your trauma service.
However, say your center is in line with its peers for management of severe traumatic brain injury (TBI). You are doing well on these patients, so there is no need to look at every single chart for this cohort. And yet you still want to keep an eye on these patients, so what do you do? To monitor this cohort:
- Run a registry report every month on TBI patients with GCS less than or equal to 8.
- The report should include basic patient information (demographics, injury, consults, etc.) plus a few measures that serve as quality indicators — for example, cerebral monitor placement within your facility’s timeframe guideline (for example, 2 hours).
- When you review the report, check for adverse events (mortality, readmission, DVT, etc.) and also for performance on the select quality indicators.
For example, a monthly registry report on this cohort might include 15 patients but show that only 2 of them did not receive a cerebral monitor within your facility’s timeframe. You should perform a deep-dive analysis of these two patients but not for all 15.
What do I do if our center does not participate in TQIP? You can still use this basic approach to performance monitoring. If an issue is a known problem for your center, focus on it as normal. If an issue is triggering one of your audit filters but is not an established problem, use registry reports to monitor for the issue and drill down only where needed.
Either way, I recommend incorporating these and other monthly registry reports into your center’s PI dashboard. A well designed dashboard provides a broad view of trauma program performance, making it easier to identify and address true problems and downgrade less pressing issues.
3. Prioritize trauma center standards
No matter what challenges a trauma program is currently facing, it has to meet the minimum standards of its verifying or designating entity. Once more, however, this does not mean you have to perform a detailed review of every relevant case. Use your registry to monitor for compliance with trauma center standards and drill down only when necessary.
For example, current ACS standards specify that certain programs must review all non-surgical admissions (NSAs) through the trauma PI process (CD 5–18). To do this, you could comb through the medical record of every NSA patient treated by the medicine service. Or you could let your registry do the heavy lifting.
My recommendation: Run a monthly registry report on all NSA patients. Again, the report should include just a few key pieces of information: complaint, injuries, admitting service and consultants. Then simply review the report, looking for indications of appropriate or inappropriate care. For example:
- Patient A: 84-year-old male, fall from standing, humerus fracture, admitted to medicine with an orthopedic surgery consult, discharged to SNF. This is an expected NSA, so you do not need to review this case in depth.
- Patient B: 48-year-old female, gunshot wound, admitted to medicine, no surgical consult, discharged home. Failure to admit this patient to a surgical service is clearly a variance in care. Perform a thorough review to understand this case, identify opportunities for improvement, forward it for a higher level of review and develop a corrective action plan.
Here’s another example. Your state trauma center standards require you to monitor undertriage. Again, you could assess every chart for appropriate triage — or you could use your registry data to monitor your center’s performance on this standard.
In this case, the monthly registry report could pull all patients with ISS > 15 who did not receive a trauma team activation. When you receive this report, review it for the major issues listed above (mortality, readmission, etc.). The report might include 12 patients who were incorrectly triaged, but only 1 with an unexpected outcome. Review that single patient to understand where triage processes went wrong, but do not perform an extensive review on the entire cohort.
(Note: If your center is facing a staffing or resource shortage, it may be worthwhile to monitor overtriage as well. This could help identify ways to limit resource utilization where appropriate.)
Other trauma standards focus on delays in care. To monitor compliance with these standards, focus on time-critical injuries and conditions such as epidural hematoma, open fracture and hemodynamic instability. Perform a full case review for these patients. For all other delays in care, note the issue and trend it for future follow-up.
This approach can also be applied to hospital-specific standards. If your facility has criteria for what injuries are always transferred to a higher level of care, these cases do not require a full case review but rather a quick review to determine whether the transfer was timely. For example, your hospital always transfers hand injuries, burns, complex pelvis injuries and pediatric trauma. Run a monthly registry report on these injuries, and you can tell at a glance which transfers require an in-depth case review.
Streamline your approach
Sharpening the focus of your performance improvement activities and leveraging registry data can help trauma program leaders develop more efficient PI processes. To summarize:
- The goal of trauma PI is to improve outcomes by reducing variances in care. Not every variance requires a full case review.
- Rather than addressing every PI issue with a case-by-case review, focus on issues in the aggregate to identify the common problems that need to be addressed. This can easily be achieved using registry data.
- Be comfortable with the fact that you may miss something, but it will not be a miss that impacts patient outcomes.
This streamlined approach to quality monitoring will help keep PI on track even as staffing shortages and other resource constraints continue.
If you would like to learn more, I invite you to join me this November for a live interactive webinar — “Mission Critical” Trauma Program Management: How to Keep Up When You and Your Team Are Running on Fumes. During this one-hour session, I will:
- Dig deeper into staffing challenges, including how to optimize agency nurses for trauma.
- Describe efficient strategies for survey prep, including keys to a smooth virtual site visit.
- Share the full results of our recent “Top Concerns in Trauma” Survey.
- Answer live questions from the audience on how to prepare a trauma program for 2022.
Registration for “Mission Critical” Trauma Program Management is now open. To reserve your seat, click below: