new tools to reduce and standardize the triage review process€¦ · texas health harris methodist...

New tools to reduce and standardize the triage review process

JW Roden-Foreman, BANR Rapier, MSNL Yelverton, RN

ML Foreman, MD

Baylor University Medical Center, Level I Trauma CenterDallas, Texas

Disclosures

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None

Background

• Over- and undertriage monitoring• Proper allocation of resources and optimal, timely care

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Modified Cribari matrixISS 0-9 ISS 10-14 ISS 15-24 ISS ≥25

Full activation OT OT AT ATPartial activation AT AT AT UT

Consultation AT AT UT UTTrauma not notified AT UT UT UT

OT = overtriage; UT = undertriage; AT = appropriate triageAdapted from Fitzpatrick MK, Graymire V, Mattice C, et al. Trauma Outcomes and Performance Improvement Course. . 2009:48.





Overtriage

The trauma team

The patient

Background


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Undertriage

The patient

The trauma team

Background


• Works relatively well for most cases

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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 pre-injury 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 17-24

• Weak association with resource requirements

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AIS 711010.5: Amputation, partial or complete, at shoulder, bilateralISS = 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

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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”

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Our question

• Regardless of ISS, who really needs a trauma activation?

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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

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Methods

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Initial development

sample

6 criteriaData

mining

Clinical expertise

~100 variables

NFTINFTI 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

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 2014Chapter 16: Performance Improvement and Patient Safety

Pages 120-121

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.

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

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What we were doing

• Step 1: Cribari matrix• Inaccurate but standardized

• Step 2: triage reviews• Accurate but unstandardized

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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)

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Standardized Triage Assessment Tool

• Combines the Cribari method with NFTI to emulate the triage review process

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NFTI

Cribari

STAT

STAT

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Full TTAs

AT

AT

OT

NFTI+

OTAT

NFTI-

Others

AT

AT

UT

NFTI+

ATUT

NFTI-

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

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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

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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

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How we used to do triage reviews

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How we do triage reviews now

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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

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Major Trauma & Triage Measurement Workgroup

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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

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

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Thank you for your time

Michael L. Foreman, MDTrauma Medical Director

[email protected]

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Questions?

new tools to reduce and standardize the triage review process€¦ · texas health harris methodist...

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