1. Performance Improvement: How Do We Improve? Deb Syverson, RN, BSN, EMT Trauma Program Manager Sanford Health – Fargo, ND

2. Performance Improvement: How Do We Improve?

3. State and Regional Trauma Performance Improvement

4. Covering the Basics Establish statute/regulations that provide confidentiality and discovery protection for all activities of Region and Statewide PI: Trauma Registry Data Performance Improvement process NDCC Chap 23-01.2-01 A trauma PI program to monitor the performance of the trauma system. The proceedings and records of the program are not subject to subpoena or discovery, or introduction into evidence in any civil action arising out of any matter that is the subject of consideration by the program.

5. Basic fundamentals in starting Regional and State Performance Improvement Basic fundamentals in starting Regional and State Performance Improvement Developing PI Process/Guidelines Developing PI Process/Guidelines Indicators/Outcomes from ND Performance Improvement Indicators/Outcomes from ND Performance Improvement OBJECTIVES

6. Trauma Registries are a MUST Trauma Registries are a MUST — All trauma designated and non-designated facilities should be participating. — Determine statewide inclusion criteria for trauma patient population you want in the registry — Create a trauma data dictionary for all users  GOOD DATA IN = GOOD DATA OUT  Very important that all users are interpreting the fields correctly  Must provide yearly trainings and modules for new users. COVERING THE BASICS COVERING THE BASICS

7. Trauma Registry Cont…. Trauma Registry Cont…. — Oversight of Trauma Registry Data  Typically your lead agency  State Epidemiologist  Data Analyst  Checking for validity, generating reports, monitoring timely submissions  Registry Training COVERING THE BASICS

8. ND – 4 Regional Trauma PI Committees ND – 4 Regional Trauma PI Committees — Led by Level II Trauma Center Physician Chair, State Medical Director, and State TPM — Multidisciplinary  Trauma Coordinators, Physicians, Advanced Practice Providers, and EMS from all level trauma centers in the region. — Meetings held quarterly  Video/teleconferencing REGIONAL PI: HOW DO WE (ND) DO IT?

9. Development of PI Guidelines/Plan Development of PI Guidelines/Plan — Mission: Continuously improve trauma care outcomes and monitor trauma patient care and system issues and provide education. — Objectives:  Trauma Coordinators, Physicians, Advanced Practice Providers, and EMS from all level trauma centers in the region - Improve patient outcomes  Identify performance improvement projects  Identify education opportunities  Maintain confidentiality  Feedback to providers, facilities, EMS, and the State Trauma Committee  NON PUNITIVE!!!!!! REGIONAL PI: HOW DO WE (ND) DO IT?

10. Process – what do we look at? Process – what do we look at? — All deaths from the Level IV and V trauma centers — Patients with an ISS > 15 that were transferred with:  Trauma Code not activated when patient met criteria  GCS <8 and no definitive airway  Transfer times > 2 hours  Trauma team leader response times > 20 minutes  Pneumo/Hemothorax identified and chest tube not placed  Pediatric patients less than 16 years of age that had CT scans (Implemented in 2011) REGIONAL PI

11. Process Cont…. Process Cont…. State Trauma Registry used to pull cases State Trauma Registry used to pull cases Cases reviewed by the State Medical Director and State TPM Cases reviewed by the State Medical Director and State TPM Facilities present cases at the regional meeting Facilities present cases at the regional meeting Recommendations and/or education is provided at the meeting along with written letter to the individual facilities or EMS agencies Recommendations and/or education is provided at the meeting along with written letter to the individual facilities or EMS agencies Regional Chair provides regional updates/issues to the State Trauma Committee Regional Chair provides regional updates/issues to the State Trauma Committee REGIONAL PI

12. REGIONAL PI – DOES IT WORK? When looking at transfers >2 hours the common factor found were delays due to CT Scans. A letter from the State Trauma Committee Chair was sent out to all hospitals regarding CT scans delaying transfers.

13. REGIONAL PI – DOES IT WORK?

14. Pediatric CT Scanning presentation Trauma Conference Pediatric CT Scanning presentation Trauma Conference Pediatric CT Scanning education at each Regional Mtg Pediatric CT Scanning education at each Regional Mtg Resource Document made available by State Tr. Coord. Resource Document made available by State Tr. Coord. Added as a “regional PI filter” – cases reviewed Added as a “regional PI filter” – cases reviewed

15. Benchmarking! Regional PI Process/Data

16. ED Intubated / GCS2 Data Report for Regions

17. Benchmarking!

19. Regional PI Process Requesting Information Data is pulled from state trauma registry Data is pulled from state trauma registry Indicators “falling out” Indicators “falling out” State Trauma Coordinator contacts hospital for “abstract” State Trauma Coordinator contacts hospital for “abstract” State Trauma Coordinator informs “Level IIs” if the patient was transferred to higher level of care – to obtain follow information State Trauma Coordinator informs “Level IIs” if the patient was transferred to higher level of care – to obtain follow information Data collated, form distributed (confidential) Data collated, form distributed (confidential) Cases presented at regional meetings Cases presented at regional meetings

21. Regional PI Process

23. SampleSample

24. 2009 vs. 2013

25. ND SE Regional Trauma PI Meeting ND SE Regional Trauma PI Meeting PI Regional indicators reviewed – cases reviewed PI Regional indicators reviewed – cases reviewed Length of stay > 2 hours Length of stay > 2 hours Cases reviewed – noted multiple radiographic studies prior to transfer, discussion Cases reviewed – noted multiple radiographic studies prior to transfer, discussion Committee decision Committee decision Letter to provider from Regional Committee Letter to provider from Regional Committee State Letter to all providers and administrators State Letter to all providers and administrators Discussed at State Trauma Committee meeting Discussed at State Trauma Committee meeting Review indicator at Regional PI meetings Review indicator at Regional PI meetings Further Actions? Pediatrics Further Actions? Pediatrics Continue to review at all trauma centers! Continue to review at all trauma centers! Example of Regional PI

27. Minnesota – South Dakota

29. State Trauma Committee State Trauma Committee — Multidisciplinary — Meetings held every other month by video/teleconference State PI Guidelines State PI Guidelines — Mission / Objectives / Process Registry Submissions Registry Submissions Indicators: Indicators: — Transfers out of State ---- “Transfer out of Level II trauma centers” — Deaths – at level II Trauma Centers ---- “predicted to Survive and Died <85 y/o” STATE PI – HOW DO WE DO IT?

30. Trauma Registry Date Submissions by All Hospitals Trauma Registry Date Submissions by All Hospitals — Reports provided to the STC on facilities that were not submitting data to the registry — Data submission essential criteria for trauma designation STATE PI – Does it work?

31. Regional Meetings – time frame Regional Meetings – time frame State Meetings – time frame State Meetings – time frame STATE PI – Volumes

32. 2013 Quarter 4

33. Sample State PI Reports: SampleSample

34. SampleSample

35. Overall Regional & State PI Impact Pleasantly Surprising Pleasantly Surprising Tripled participation at the regional meetings Tripled participation at the regional meetings Has improved communication between sending and receiving facilities Has improved communication between sending and receiving facilities

36. Provided great educational opportunities: Provided great educational opportunities: — Annual Statewide Trauma Conference — Annual State Trauma Coordinators’ face to face meetings — Improvement to individual hospital PI process Overall PI Impact on Patient Care

37. Start With The Basics Start Simple, Start Now! Amy Eberle, RN Trauma Coordinator Sanford Health – Bismarck ND amy.eberle@sanfordhealth.org 701.323.2939 Ruth Hursman, RN State Trauma Coordinator Division of EMS & Trauma – Bismarck ND rhursman@nd.state.gov 701.328.1026 Great Resource People…..

38. Inclusive State Trauma System An inclusive state trauma system should provide integrated, appropriate, and standardized medical care to trauma patients, wherever in the state the injury should happen. Care Education Prevention By Definition:

39. All hospitals and providers expected to participate. All hospitals and providers expected to participate. Trauma resources to be spread amongst all providers. Trauma resources to be spread amongst all providers. Hospitals to maintain a basic level of function. Hospitals to maintain a basic level of function. Healthcare Providers need to maintain a standardized level of trauma care. Healthcare Providers need to maintain a standardized level of trauma care. What does Inclusive mean?

40. All hospitals and providers expected to participate. All hospitals and providers expected to participate. — Legislature mandated participation in 2009 Trauma resources to be spread amongst all providers. Trauma resources to be spread amongst all providers. Hospitals to maintain a basic level of function. Hospitals to maintain a basic level of function. — State trauma committee site visits — Addition of State Trauma Medical Director 2012 Healthcare Providers need to maintain a standardized level of trauma care. Healthcare Providers need to maintain a standardized level of trauma care. — All ED providers must pass Advanced Trauma Life Support© — Rural Trauma Team Development Course (made available) Towards Inclusive ….the ND Historical Journey……

42. North Dakota: An Inclusive State-Wide Trauma System All hospitals and providers expected to participate All hospitals and providers expected to participate — 2011 - All hospitals designated! Level I - 0 Level II - 6 Level III - 0 Level IV - 9 Level V - 30

43. Standardized Education Available Standardized Education Available — ATLS® mandatory for all practitioners (M.D., NP, PA who cover the ED) — Rural Trauma Team Development Course® — Trauma Treatment Guidelines Manual Healthcare providers need to maintain a standardized level of trauma care. Healthcare providers need to maintain a standardized level of trauma care. — PI process for Regional continues — State PI process was implemented!! — Evidence based care - State Trauma Treatment Guidelines ND: An Inclusive State-Wide Trauma System ND: An Inclusive State-Wide Trauma System Important everyone plays fair in the sandbox!

44. State Trauma Medical Director State Trauma Medical Director — 2011 Legislative session provided small appropriations for a contracted position — Provides leadership/direction – keeps everyone on the same page — “Rule Enforcer” — Provides Education/Outreach — Integrates with other services: — Disaster, EMS, Injury Prevention, National Organizations ND: An Inclusive State-Wide Trauma System ND: An Inclusive State-Wide Trauma System

45. Moving Forward….. Continue to maintain our State Trauma RegistryContinue to maintain our State Trauma Registry Continue to develop (revise) our PI processContinue to develop (revise) our PI process Continue our Legislative EffortsContinue our Legislative Efforts — Stabilize the State Trauma Medical Director position — Obtain adequate manpower at the Department of Health — Secure adequate funding for trauma system activities  Education/Outreach  Trauma designation visits  Trauma Registry support Continue to build leadership Continue to build leadership Enhance Resources Enhance Resources Continue to educate the Public Continue to educate the Public ND: An Inclusive State-Wide Trauma System ND: An Inclusive State-Wide Trauma System What’s Next??

46. Performance Improvement: How Do We Improve? State & Regional PI State & Regional PI Inclusive State-Wide Trauma System Inclusive State-Wide Trauma System Priorities for Optimal Trauma Care Priorities for Optimal Trauma Care