level iii tqip pilot program - web4.facs.org

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Level III TQIP Pilot Program

Holly Michaels

TQIP Program Manager

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Welcome

• Thank you for your ongoing participation in the TQIP Level III pilot program!

• Center data submission, feedback, and participation in educational activities has been instrumental in program development.

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

33 ACS Verified only, 105 state designated only, 29 both, 22 in process = 189 total

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Pilot Year

Goals:

• To determine the unique needs of Level III’s in regards to data collection and analysis, reporting, and education.

• To offer trauma center benchmarking and training at all levels of care.

• To gain a broader understanding of trauma care across the system.

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Pilot Year

Activities:

• Data submission

• Education- monthly quiz questions and online modules

• Reports- Data Quality Report and Risk-adjusted Benchmark Report- Summer 2016

• Pilot evaluation- Summer 2016

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Level III Program

• Launch planned for July 1st

• Early registration will open in April

• Fee: $7,000

• Stay tuned for more information on getting started!

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Level III TQIP Data Quality Report

Avery Nathens, M.D., Ph.D.

TQIP Medical Director

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

• Available on the NTDB Data Center – as will future reports • Don’t forget the report addendum which contains useful

information for understanding the report • This report covers 2014 admissions

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Why a data quality report?

• Start of pilot began prior to education/training o TQIP has an opportunity to explore data quality for

level III TQIP through NTDB o Helps focus further education

• Level III TQIP pilot participants have an opportunity to learn about their data quality and how it impacts future reports

• Level III TQIP pilot participants have an opportunity to become familiar with TQIP reporting before full enrollment

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Level III TQIP Inclusion Criteria • Injury: ICD-9 800-959.9 excluding late effects, superficial

injuries, foreign bodies • Mechanism: Blunt or penetrating (primary external cause)

or abuse related external cause code excluding burns>20% TBSA/ABA transfer criteria

• Severity: At least one AIS>2 in body region apart from external (min ISS=4)

• Known ED or hospital discharge • ED discharge disposition is admit, transferred, or died • No pre-existing advanced directive to withhold life

sustaining interventions • Vital signs on arrival (SBP>0, pulse>0, or GCS>1)

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Cohorts • All Patients • Severe Traumatic Brain Injury (sTBI)

• Initial ED/Hospital GCS ≤ 8 • Brain AIS ≥ 3

• Pediatrics • Age < 15

• Elderly • Age ≥ 65

• Isolated Hip Fractures (IHF) • Age ≥ 65, mechanism of fall, hip fracture & no other significant injuries • Not part of any other group

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Important Data Quality Findings Model Variables • 17 hospitals with >10% unknown race

• 9 with >50% unknown race

• 36 hospitals with >5% unknown SBP • 12 with >10% unknown SBP

• 16 hospitals with >5% unknown pulse

• 77 hospitals with >5% unknown GCS motor

• 33 hospitals with >20% unknown GCS motor • 16 with >40% unknown GCS motor

• 36 hospitals with >5% unknown respiratory rate

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Important Data Quality Findings Model Variables • Comorbidities:

• 15 hospitals with >10% unknown comorbidities • 10 hospitals with >80% NA comorbidities (no comorbids)

• Most patients had no comorbid conditions • 21 hospitals with <3% NA comorbidities (no comorbids)

• Almost every patient had a comorbid condition • 26 hospitals with >50% ‘Other’ comorbidities

• 10 hospitals with an average BMI above 40

• 29 with 100% unknown BMI

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Challenges

• Improving data quality on essential fields • Limited patient count • Defining and collecting those data which are most important to level III hospitals

© A

mer

ican

Co

llege

of

Surg

eon

s 20

16.

All

righ

ts r

eser

ved

Wo

rld

wid

e.

Looking to the Future

• Risk-adjusted report due in early Summer 2016 • Will cover 2014 admission data – same as the DQ report • Mortality modeling; transfer modeling or profiling • Working towards defining the most appropriate risk-adjusted report for level III hospitals

level iii tqip pilot program - web4.facs.org

Documents