New tools to reduce and standardize the triage review process

Transcription

1 New tools to reduce and standardize the triage review process JW Roden-Foreman, BA NR Rapier, MSN L Yelverton, RN ML Foreman, MD Baylor University Medical Center, Level I Trauma Center Dallas, Texas None Disclosures 2

2 Background Over- and undertriage monitoring Proper allocation of resources and optimal, timely care Modified Cribari matrix ISS 0-9 ISS ISS ISS 25 Full activation OT OT AT AT Partial activation AT AT AT UT Consultation AT AT UT UT Trauma not notified AT UT UT UT OT = overtriage; UT = undertriage; AT = appropriate triage Adapted from Fitzpatrick MK, Graymire V, Mattice C, et al. Trauma Outcomes and Performance Improvement Course :48. 3 Overtriage The trauma team The patient

3 Background Over- and undertriage monitoring Proper allocation of resources and optimal, timely care Modified Cribari matrix ISS 0-9 ISS ISS ISS 25 Full activation OT OT AT AT Partial activation AT AT AT UT Consultation AT AT UT UT Trauma not notified AT UT UT UT OT = overtriage; UT = undertriage; AT = appropriate triage Adapted from Fitzpatrick MK, Graymire V, Mattice C, et al. Trauma Outcomes and Performance Improvement Course :48. 5 Undertriage The patient The trauma team

4 Background Over- and undertriage monitoring Proper allocation of resources and optimal, timely care Modified Cribari matrix ISS 0-9 ISS ISS ISS 25 Full activation OT OT AT AT Partial activation AT AT AT UT Consultation AT AT UT UT Trauma not notified AT UT UT UT OT = overtriage; UT = undertriage; AT = appropriate triage Adapted from Fitzpatrick MK, Graymire V, Mattice C, et al. Trauma Outcomes and Performance Improvement Course :48. Works relatively well for most cases 7 Some of ISS s limitations AIS based on consensus AIS not always well-scaled Gives equal weight to the six regions Groups brain, skull, and neck Not accounting for multiple injuries to the same region Inability to account for preinjury comorbidities or frailty Differing mortality rates for the same ISS values resulting from different AIS triplets 21% mortality from AISs 5, 0, and 0 vs. 0% from 4, 3, and 0 Non-monotonic relationship between ISS and mortality 15% mortality for ISS 16 vs. 10% for ISS Weak association with resource requirements 8

5 AIS : Amputation, partial or complete, at shoulder, bilateral ISS = 25 Some ISS are more equal than others Elderly, frail, multiple-comorbidity patients Minimal physiologic reserves Young, healthy, active patients Their systems are more robust to injury 10

6 ACS-COT s solution [E]valuating patients with or without major injury for the different levels of activation. The definition of major injury requiring the resources of the highest level of activation is determined by the local center 11 Our question Regardless of ISS, who really needs a trauma activation? 12

7 Our goal Develop a measure of major trauma that Is automated, Uses common registry fields, Has a clear cutoff, and Addresses the inaccuracies of ISS 13 Initial development sample Methods ~100 variables Clinical expertise Data mining 6 criteria 14

8 NFTI criteria PRBC within 4 hours ED to OR within 90 minutes ED to Interventional Radiology ED to ICU and ICU LOS 3 calendar days Therapeutic ventilation within 3 days Death within 60 hours NFTI Results from 9,737 patients Being NFTI+ was associated with higher trauma response levels, older age, higher ISS, worse ED vitals, longer LOS, and mortality Only 13 of 561 deaths were not NFTI+ All in patients with DNRs Using ISS >15 missed 73 mortalities 46 with DNR orders Resources for Optimal Care of the Injured Patient 2014 Chapter 16: Performance Improvement and Patient Safety Pages A simple method to identify [potential overtriage and undertriage cases] is a matrix method evaluating patients with or without major injury for the different levels of activation. The definition of major injury is determined by the local center, often by data readily available in the trauma registry. Patients with an ISS greater than 15 for which the highest level of TTA was not activated should be reviewed in depth. Other factors to consider include [patients] requiring blood transfusion as part of their initial resuscitation or requiring intubation, intensive care unit admission, emergent surgery or interventional catheter-based control of hemorrhage, or intracranial pressure monitoring.

9 Back to Cribari Cribari method is an initial flag for additional review Triage reviews have their own issues Time intensive Largely subjective, entirely unstandardized Valid multi-institutional comparisons impossible Valid within-institution comparisons difficult 17 What we were doing Step 1: Cribari matrix Inaccurate but standardized Step 2: triage reviews Accurate but unstandardized 18

10 Our second goal Develop a measure that Is automated, Uses common registry fields, Addresses the inaccuracy of ISS-based triage determinations, and Partially standardizes the secondary review process (Reduce our triage rates) 19 Standardized Triage Assessment Tool Combines the Cribari method with NFTI to emulate the triage review process 20

11 Full TTAs STAT Others Cribari AT OT AT UT NFTI NFTI+ NFTI+ NFTI- NFTI- STAT AT AT OT AT UT AT 21 Methods Prediction: Overtriage associated with increased odds of D/C home from the ED, shorter LOS, decreased odds of mortality, and decreased odds of complication Opposite for undertriage 2017 arrivals (n=3,457) Regressions controlled for age, GCS, and SBP on arrival 22

12 Results: overtriage Cribari method 32% D/C home from ED (p = 0.967) LOS 48% shorter (p < 0.001) 15 (3%) mortalities (p < 0.001) 83% less likely to have complication (p<0.001) 491 (60%) overtriages STAT 47% D/C home from ED (p < 0.001) LOS 65% shorter (p < 0.001) 0 (0%) mortalities (p < 0.001) 94% less likely to have complication (p<0.001) 316 (39%) overtriages 23 Results: undertriage Cribari method 2% D/C home from ED (p < 0.001) LOS 52% longer (p < 0.001) 12 times more likely to die (p < 0.001) 4 times more likely to have complication (p<0.001) 271 (8%) undertriages STAT 0% D/C home from ED (p < 0.001) LOS 130% longer (p < 0.001) 40 times more likely to die (p < 0.001) 16 times more likely to have complication (p<0.001) 75 (3%) undertriages 24

13 How we used to do triage reviews 25 How we do triage reviews now 26

14 Conclusions Better out-of-the-box sorting with STAT Fewer cases get triage reviews NFTI criteria hint where to look More accurate valid internal monitoring Limitation: all single-center data 27 Major Trauma & Triage Measurement Workgroup Aspirus Wausau Hosp: Wausau, WI Cook Children's Med Cnt: Fort Worth, TX Parker Adventist Hosp: Parker, CO St. Mary-Corwin Med Cnt: Pueblo, CO Avista Adventist Hosp: Louisville, CO Froedtert Hosp: Milwaukee, WI Penn State Hershey Med Cnt: Hershey, PA St. Thomas More Hosp: Canon City, CO Baylor Scott & White: Grapevine, TX George Washington Univ Hosp: Washington, DC Penrose-St. Francis Health: Colorado Springs, CO Texas Health Harris Methodist Hosp: Fort Worth, TX Baylor Scott & White: Temple, TX Greenville Memorial Hosp: Greenville, SC Porter Adventist Hosp: Denver, CO Univ Arkansas Med Sciences: Little Rock, AR Baylor Univ Med Cnt: Dallas, TX Helen DeVos Children's Hosp: Grand Rapids, MI Regions Hosp: Saint Paul, MN Univ Colorado Med Cnt of the Rockies: Loveland, CO Castle Rock Adventist Hosp: Castle Rock, CO John Peter Smith Hosp: Fort Worth, TX Rhode Island Hosp: Providence, RI Univ Colorado Memorial Hosp: Colorado Springs, CO Children's Hosp: Dallas, TX Littleton Adventist Hosp: Littleton, CO St. Anthony Hosp: Lakewood, CO Univ North Carolina Med Cnt: Chapel Hill, NC Children's Hosp: Philadelphia, PA Longmont United Hosp: Longmont, CO St. Anthony North Campus: Westminster, CO Univ Wisconsin Hosp & Clinics: Madison, WI Children's Minnesota: Minneapolis, MN Mercy Regional Med Cnt: Durango, CO St. Anthony Summit Med Cnt: Frisco, CO Children's Minnesota: Saint Paul, MN Methodist Hosp: Dallas, TX St. Francis Med Cnt: Colorado Springs, CO 28

15 Conclusions Better out-of-the-box sorting with STAT Fewer cases get triage reviews NFTI criteria hint where to look More accurate valid internal monitoring Limitation: single-center data Multi-center study Preliminary results promising Possibly valid multi-institutional comparisons 29 Thank you for your time Questions? Michael L. Foreman, MD Trauma Medical Director 30