Tool that might be used to improve the trauma system in the region

Witaya Chadbunchachai

Trauma and Critical Care Center

Khon Kaen Regional Hospital

Risk chance

Industrial hazard

terrorism

earthquake

Thailand risk areaThailand risk area””landslide

Thai EMS situation observed by the Swedish EMS mission team during Tsunami catastrophe :-

1. Weak coordination at a national level 2. Inadequate dispatch center at regional and local level 3. The need for a national emergency phone number; known

to the public 4. Poor training of rescue foundation staff as well as no

certification of volunteers 5. Non specialized and non standardized training for EMS

personnel 6. No or insufficiently developed helicopter, sea rescue 7. Weak emergency rescue procedures and standards

• “It couldn’t happen to us”

is an un acceptable excuse for being ill prepared to deal with a major incident.

T.J. Hodgetts

K. Mackway-Jones

เพราะเชื่��อว่�า “เหตุ�การณ์�อย่�างนี้��ไม่�เก�ดขึ้��นี้ในี้บ้ านี้ขึ้องเราหรอก”

ก!เลย่ไม่�คิ�ดที่��จะเตุร�ย่ม่การร&บ้ม่�อก&บ้สถานี้การณ์� คิว่าม่เชื่��อนี้��เป็*นี้คิว่าม่เชื่��อที่��ใชื่ ไม่�ได และร&บ้ไม่�ได

Development Frame : An Development Frame : An Inclusive Trauma Care Inclusive Trauma Care SystemSystem • PREVENTION

• TRAINING

• EVALUATION

AllInjuredPatients

MajorTraumaPatients

PREHOSPITAL• Communication• Medical Direction• Triage• Transport

ACUTE CARE FACILITY WITHIN A TRAUMA

SYSTEM other injured patients

TRAUMA CENTER most severity injured or

SPECIALTY CARE FACILITY peds, burns, and so on

INTERFACILITYTRANSFER

REHABILITATION

Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, MD, 1992

Trauma RegistryTrauma Registry

ObjectiveObjective

To establish data base to monitor and modify To establish data base to monitor and modify trauma care systemtrauma care system

To define nature and extend of trauma for To define nature and extend of trauma for preventionprevention

To define factors for patients mortality and To define factors for patients mortality and morbiditymorbidity

To determine manpower requirement To determine manpower requirement

To estimate expendituresTo estimate expenditures

Ideal Character of Injury Surveillance System

Ideal Character of Injury Surveillance System

1.1. UsefulnessUsefulness

2. The quality of surveillance2. The quality of surveillanceSimplicitySimplicityFlexibilityFlexibility

AcceptabilityAcceptabilitySensitivitySensitivity

Positive predictive valuePositive predictive valueRepresentativeRepresentative

TimelinessTimeliness

3. Validation of Data Collection Methods3. Validation of Data Collection Methods

4. Reliability of The Coding System4. Reliability of The Coding System

Ideal Character of Injury Surveillance System

Ideal Character of Injury Surveillance System

Key Components

Team work Work sites Data collection equipment Data Collection form Data collection program with a data entry

manual Data flow system Data analysis and report

Work site at Work site at Registration UnitRegistration Unit

Work siteWork site at ERat ER

Work site at Work site at ERER

Minimal Basic Data SetMinimal Basic Data Set

Modified from Modified from

* Text Book of Trauma* Text Book of Trauma

Champion & FelicianoChampion & Feliciano

Chapter 2 Trauma ScoringChapter 2 Trauma Scoring

Minimal Basic Data SetMinimal Basic Data Set

Modified from Modified from

* Text Book of Trauma* Text Book of Trauma

Champion & FelicianoChampion & Feliciano

Chapter 2 Trauma ScoringChapter 2 Trauma Scoring

• Minimal basic data set– Hospital identifier No.– Hospital patient No.– Age– Sex– Race/Ethnic origin– E-code– Transferring hospital– Transferred to, from or not transferred– Date of Admission– Time of Admission

American College of SurgeonAmerican College of SurgeonAmerican College of SurgeonAmerican College of Surgeon

• On arrival in ER– Systolic BP, pulse, RR, GCS

• In OR– CPT, code, date, time, surgeon, identifier

• Diagnosis– ICD – 9 (List)

• Disposition– Died (Yes or No)– Date of discharge– Disposition if alive

American College of SurgeonAmerican College of SurgeonAmerican College of SurgeonAmerican College of Surgeon

Data Recording Form

Injury Surveillance Record Hospital name …………..…………… Province………………………..…...

Present 1 In this province address 2 Not in this province

3 Unknown First name…………………….…….Last name…………….… HN…………………………Sex 1 Male 2 Female Date of Birth……………..…or Age ………….. Yr …...... Month. Or Approximately ….… Yr.Occupation 01 Govt. Officials 02 Police/Soldier 03 Govt. enterprise 04 Private company

05 Unskilled worker 06 Business 07 Agriculture 08 Students others……….

Date occurred ……………………………….…..Time occurred ………………………Date arrived at hospital……………..………Time arrived at hospital………..……Location District……………………………….Province………………………………… 1 Home 2 Residential institution 3 School, Public Admin Area 4 Sport, athletic area 5 Street/Hi-way 6 Trade and service area 7 Industrial and construction area 8 Farm 9 Others………………

Intention 1 Accident 2 Self-harm 3 Assault Unknown

OccupationalInjury 1 Yes 0 No Unknown

External causes of injury 1 Transport accidents 1.1 Type of injured person 1 pedestrian 2 Driver 3 Occupants 4 Unknown 1.2 Vehicle of the injured 1 Bi/tricycle 2 Motorcycle 3 Motor-tricycle 4 Personal car 5 Pick up/Van 6 Heavy truck 7 Trailer-Truck 8 Mini-Bus 9 Buses 10 Others (Specified)……………………………… 1.3 Injured due to 20 Fall from vehicle 21 Vehicle over turned, sank etc. Collision with…………….............. Others (Specified)……………… 2 Others injuries (Specified) ………………………………………………………………………………… 3 Unknown

Risk behaviors

1. Alcohol 1 Use 0 Not use Unknown

3. Seat belt 1 Use 0 Not use Unknown

2. Drugs/ Medication 1 Use (Specified)

………………….. 0 Not use Unknown

4. Helmet 1 Use 0 Not use Unknown

Transportation of the injured to hospital 1 From injured Person who transport No Not known Site or others 1 EMS 2 Charitable Volunteers……………………………………..

3 Police

Others…………………………………………………………….. 2 From health facility: Name ……………….….Province…………. 2.1 By Ambulance With person to take care (specified professional)

……………. 1. No person taking care 0 Not ambulance 2.2 With referral letters 1 Yes 0 No

First aid / care while transport

Breathing care 1 Yes-appropriate 2 Yes but not appropriate 3 Not needed 0 No

Bleeding care 1 Yes-appropriate 2 Yes but not appropriate 3 Not needed 0 No

Splint / Slab 1 Yes-appropriate 2 Yes but not appropriate 3 Not needed 0 No

IV fluid 1 Yes-appropriate 2 Yes but not appropriate 3 Not needed 0 No

Seen At. ER (Record only patients who are to be R/O Head injury / Observe / Admit / Dead at ER., Refer) Vital sign BP…………….........mm/Hg Pulse ……......………/ min R.R ………………………. / minConsciousness description...............................................................................................Coma Scale ..........................................

Type of injury cause 1 Blunt 2 Penetrating 3 Blunt and penetrating Others

Date Disposition from ER. ……………………………………………………………………….Time……………………………….By 1 D.B.A. 2 D/C 3 Refer 4 Against advice 5 escape 6 Dead at ER. 7 Admission to …………….

DIAGNOSIS (Specified organ and injury in detail) If admitted, do not fill at ER.1………………………………………..(BR………AIS……..) 4………………….………………..(BR………AIS……..)2………………………………………..(BR………AIS……..) 5………………….………………..(BR………AIS……..)3………………………………………..(BR………AIS……..) 6………………….………………..(BR………AIS……..)

Date Discharged from ward ……………………………………………………………………………Outcome 1 Improve 2 Refer 3 Against advice 4 Escape 5 Dead 6 Ask to go back to die at home

Recorders name………………………………………………………………………………

Fourth Phase (1999)Fourth Phase (1999)

Trauma PatientsTrauma Patients Data collection by ER nurseData collection by ER nurseAnd trauma center clerkAnd trauma center clerk

Immediate key in on scene at ERImmediate key in on scene at ERBy trauma center clerk By trauma center clerk

DischargeDischarge AdmitAdmit

Summarized form for Dx, BR, Summarized form for Dx, BR, AIS and key in byAIS and key in by

trauma center nurse at trauma center nurse at Trauma Center Office Trauma Center Office

Analysis by IS output Analysis by IS output program and trauma program and trauma center programmer center programmer

Documents

Number of Injury Classified by Type

7392 7349

10020 10504 10965

133751370513071

15140

1670217903

1877320091

23268 2282623500

6954 7615 7883 8269 91269893

9316 9452

6313

77916117

13510 14048

9087

0

5000

10000

15000

20000

25000

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Cases

Traffic Others Total

50

Number of Dead Classified by Type

291 294

352

271

327 331

412 409434

366

40 44

93112 107 109 126 135 151 140

331 338

445

383

434 440

538 544585

506

0

100

200

300

400

500

600

700

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Cases

Traffic Others Total

Age and Sex of Injury 2005

2030 (63%)

1194 (37%)

3894 (72%)

1513 (28%)

4218 (74%)

1512 (26%)

2470 (70%)

1077 (30%)

1749 (68%)

841 (32%)

985 (62%)

593 (38%)488 (60%)

323 (40%)286 (47%)327 (53%)

0

500

1000

1500

2000

2500

3000

3500

4000

4500No

<10 10 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 >70 Age

Male Female

Type of External Cause of Injury 2005Type of External Cause of Injury 2005

9452 (96%)

366 (4%)

3111 (99%)

38 (1%)

4230 (100%)

8

2747 (100%)

1

2433 (99%)

31 (1%)0

2000

4000

6000

8000

10000

Traffic Fall Inanimate Force Animate Force Assualt

No Dead

Organ Injury of the Admitted Case 2005Organ Injury of the Admitted Case 2005

3391 (91%)

335 (9%)

856 (98%)

2 (2%)

925 (100%)

4

901 (97%)

31 (3%)

1277 (90%)

137 (10%)

0

500

1000

1500

2000

2500

3000

3500

Head Wrist&Hand Multiple Inj.

No DEAD

Dead of Organ Injury and External Cause of Injury 2005

Dead of Organ Injury and External Cause of Injury 2005

314 (82%)

38 (10%)26 (7%)

5 (1%)

150 (91%)

5 (3%)_9 (5%)1 (1%)

68 (88%)

1 (1%)8 (11%)0

0

50

100

150

200

250

300

350

Traffic Fall Assualt

Head MultipleThorax Abdomen

Day in Week of Injury 2005Day in Week of Injury 2005

3155 (98%)

63 (2%)

3193 (98%)

66 (2%)

3169 (98%)

59 (2%)

3171 (97%)

83 (3%)

3457 (98%)

68 (2%)

3823 (98%)

89 (2%)

3572 (98%)

78 (2%)0

500

1000

1500

2000

2500

3000

3500

4000

Mon Tue Wed Thu Fri Sat Sun

No. Dead

10,946 (47%)7,999 ( 34%)

4,555 (19%)

0.00-08.00 am 08.00 am.-04.00 pm. 04.00 -12.00 pm.

Time of Arrival 2005Time of Arrival 2005

24.4626.5516.36 17 17.39

20.726.48

35.39

0

10

20

30

40

19981999200020012002200320042005

Helmet Use of Motorcycle Rider with Traffic Accident in Khon Kaen Municipality

%

41.42 38.74 37.09 34.6531.71

36.61

3137.24

0

10

20

30

40

50

1998 1999 2000 2001 2002 2003 2004 2005

Alcohol Use of Driver Injured in Transport Accident

in Khon Kaen Municipality %

80.372.773.0

70.174.179.5

88.0

66.171.761.1

65.861.7 59.965.775.2

55.249.141.549.245.8

36.737.2

49.141.2

3.11.92.62.62.82.42.22.2

0.0

20.0

40.0

60.0

80.0

100.0

0 - 0.25 0.25 - 0.5 0.5 - 0.75 0.75 - 1.0

Dead Rate by Severity Classified by TRISS

1998 1999 2000 2001 2002 2003 2004 2005

%

Utility of trauma registryUtility of trauma registry

Traffic Injured Patients Data for Insurances Traffic Injured Patients Data for Insurances Office every morningOffice every morning

Public ServicePublic Service

Trauma AuditingTrauma Auditing Medical AuditMedical Audit Nursing AuditNursing Audit Referral AuditReferral Audit EMS AuditEMS Audit ER AuditER Audit

Utility of trauma registryUtility of trauma registry

Trauma preventionTrauma prevention

Provincial Safety Committee review Provincial Safety Committee review situation monthly situation monthly

Medical Institute for Injury and Medical Institute for Injury and Disaster Disaster

Epidemiology Department ; MOPHEpidemiology Department ; MOPH

MonitoringMonitoring

Study and ResearchStudy and Research

Ps Ps = 1/1+e= 1/1+e-b-b

PsPs = Probability for survival= Probability for survival

ee = 2.7183 (base on Napierian logarithms)= 2.7183 (base on Napierian logarithms)

bb = b0+b1(= b0+b1(RTSRTS)+b2()+b2(ISSISS)+b3()+b3(AA))

RTSRTS = Revised Trauma Score= Revised Trauma Score

ISSISS = Injury Severity Score= Injury Severity Score

AA = 1 if age >54= 1 if age >54

= 0 if age <54= 0 if age <54

Severity Assessment Severity Assessment TRISS MethodologyTRISS Methodology

1.1. GCSGCS

2.2. Blood pressureBlood pressure

3.3. Respiratory rateRespiratory rate

4.4. ISSISS

5.5. AgeAge

6.6. Mechanism of injuryMechanism of injury

The Variable for Calculation of PsThe Variable for Calculation of Ps

Trauma AuditingTrauma Auditing Medical AuditMedical Audit

Nursing AuditNursing Audit

Referral AuditReferral Audit

EMS AuditEMS Audit

ER AuditER Audit

Recent ApplicationRecent ApplicationRecent ApplicationRecent Application

• Trauma registryTrauma registry

• Medical recordMedical record

• Trauma audit recording formTrauma audit recording form

• Guideline for recording data and Guideline for recording data and definitiondefinition

• Peer group reviewPeer group review

Component for Trauma AuditComponent for Trauma Audit

Hospital Trauma Audit Committee Assessment IHospital Trauma Audit Committee Assessment I

Hospital Trauma Audit Committee Assessment IIHospital Trauma Audit Committee Assessment II

• LeaderLeader• Peer groupPeer group

– SurgeonSurgeon– Neuro SurgeonNeuro Surgeon– CVTCVT– AnesthetistAnesthetist– OrthopedistOrthopedist

• CoordinatorCoordinator

Peer ReviewPeer Review

• Set up committeeSet up committee

• Set up the content for auditSet up the content for audit

• Set up the coordinatorSet up the coordinator

• Committee meetingCommittee meeting

• Design the time, date, place for reviewDesign the time, date, place for review

• Peer group reviewPeer group review

• Analyze and reportAnalyze and report

Technique for AuditTechnique for Audit

Death Rate of Patient Death Rate of Patient Classified by Severity of Injury in 1994Classified by Severity of Injury in 1994

PsPs NumberNumber DeathDeath PercentPercent

0.00-0.250.00-0.25 8989 8080 89.989.9

>0.25-0.50>0.25-0.50 7575 4949 65.365.3

>0.50-1.00>0.50-1.00 2,5462,546 8888 3.53.5

Before Audit Filter ApplicationBefore Audit Filter Application

Grouping for Type of Mortality Grouping for Type of Mortality by Trauma Audit Committee in 1994by Trauma Audit Committee in 1994

Type of MortalityType of Mortality NumberNumber DeathDeath %%

Non-preventable deathNon-preventable death 8585 7676 89.489.4

Potentially preventable deathPotentially preventable death 8585 5959 69.469.4

Preventable deathPreventable death 2,5402,540 8282 3.23.2

Before Audit Filter Application Before Audit Filter Application

Trauma Care ImprovementTrauma Care Improvementby Participatory Action Researchby Participatory Action Research

IdentifyingProblem

UnderstandingCause

ImplementationSuggesting

Solution

Evaluation

IdentifyingProblem

UnderstandingCause

ImplementationSuggesting

Solution

Evaluation

Trauma Audit for Trauma Service Development Trauma Audit for Trauma Service Development 1994 –19951994 –1995

Identifying Problem Understanding Cause

Implementation

Suggesting SolutionEvaluation

Team TR

Trauma Registry

TRISS table (Ps>0.5: MR=3.5)

TA Committee

Dead case review- Preventable dead rate (3.2%)- Factor for MM.

Audit filter committee

Audit filter setting

Audit filter (1 ed.)

TA committee

Implementation

Process modification

TA committee

Evaluation

Ps>0.5 : MR=2.8%

Preventable dead rate = 2.7%

Evaluation of Trauma Audit Project 1996Evaluation of Trauma Audit Project 1996

Identifying Problem Understanding Cause

Implementation

Suggesting SolutionEvaluation

TA committee

Seminar and discussion

Preventable dead rate was still high

- Practical limitation in some

iterm of audit filter

- Limit to only surgeon

- Unknown compliance

- System inadequacy was not

solvedTA committee

Evaluation

Ps>0.5 : MR=2.8%

Preventable dead rate = 2.7%

Identifying Problem Understanding Cause

ImplementationSuggesting SolutionEvaluation

Preventable dead rate wasstill high

Ps > 0.5 MR 94 = 3.5% MR 95 = 2.8%Pv dead rate 94 = 3.2%

95 = 2.7%

- Practical limitation in some item of audit filter

- The project limit to only surgeon

- System inadequacy was not solved

Process, Khonledge System

Medical Audit FilterCommittee

Audit Filter Setting

Medical Audit Filter(2nd ed.)

Nursing Audit FilterCommittee

Audit Filter Setting

Nursing Audit Filter

Patient care leadteam

Brain strom forsolution

Solution

Quality Improvement Team - Doctor - Nurse

Implementation

Process System Modification

TA Committee

Evaluation

Ps > 0.5 MR 97 = 2.7%Pv dead rate 97 = 2.1%

Medical and Nursing Audit for the Management Medical and Nursing Audit for the Management of Traumatic Patient 1997 - 1998of Traumatic Patient 1997 - 1998

Study on PerformanceStudy on Performance

FollowingFollowing

the Key Performance Indicatorthe Key Performance Indicator

for Trauma Carefor Trauma Care

Khon Kaen HospitalKhon Kaen Hospital

Study on PerformanceStudy on Performance

FollowingFollowing

the Key Performance Indicatorthe Key Performance Indicator

for Trauma Carefor Trauma Care

Khon Kaen HospitalKhon Kaen Hospital

Witaya ChadbunchachaiWitaya Chadbunchachai

Trauma and Critical Care CenterTrauma and Critical Care Center

Khon Kaen HospitalKhon Kaen Hospital

Conceptual Frame WorkConceptual Frame WorkConceptual Frame WorkConceptual Frame Work

• Set up system of medical care quality Set up system of medical care quality assessmentassessment

• Auditing system - dead case peer reviewAuditing system - dead case peer review

• Set up audit filterSet up audit filter

• ImplementationImplementation

• EvaluationEvaluation

Problems in Previous ProjectsProblems in Previous Projects

• Completeness of audit filterCompleteness of audit filter

• Cooperation of personnelCooperation of personnel

KPIs enhanced the efficiency of trauma care.KPIs enhanced the efficiency of trauma care.

Copes :[ J. Trauma 1995;38:432-438]Copes :[ J. Trauma 1995;38:432-438]

Performance IndicatorPerformance Indicator

:- Statistic that reflected the quality :- Statistic that reflected the quality of care process leading to outcomes.of care process leading to outcomes.

Performance ManagementPerformance Management

:- Method that manages personnel to :- Method that manages personnel to comply with KPIs.comply with KPIs.

ObjectivesObjectivesObjectivesObjectives

• Establishing the KPIs for trauma careEstablishing the KPIs for trauma care

• Establishing the Performance Establishing the Performance Management System for personnel in Management System for personnel in trauma care to comply with KPIstrauma care to comply with KPIs

MethodMethodMethodMethod

1. Preparation1. Preparation

– KPIs establishmentKPIs establishment• Committee making KPIsCommittee making KPIs• Review by 3 expertsReview by 3 experts

– System for performance managementSystem for performance management• Computer program for collecting dataComputer program for collecting data• Collecting data teamCollecting data team• Various formVarious form

(March - April 2000)(March - April 2000)

2. Implementation2. Implementation

– Meeting and trainingMeeting and training– CMECME

• Morning reportMorning report• Case conferenceCase conference• MM conferenceMM conference• X-ray conferenceX-ray conference

– OrientationOrientation– Solving problem of system inadequacySolving problem of system inadequacy

(May - June 2000)(May - June 2000)

MethodMethodMethodMethod

3. Outcome Study3. Outcome Study

(July - December 2000)(July - December 2000)

Inclusion Inclusion - all trauma admission- all trauma admission- all trauma dead- all trauma dead

ExclusionExclusion - underlying disease- underlying disease

EvaluationEvaluation - Preventable dead rate- Preventable dead rate- Performance rate- Performance rate- Compare result with 1995, - Compare result with 1995, 19981998

MethodMethod

4. Analysis4. Analysis

(January - June 2001)(January - June 2001)

MethodMethod

ResultsResultsResultsResults

1. Number of trauma patients1. Number of trauma patients

NoNo Admit Admit Dead Dead

Jul - Dec 1994Jul - Dec 1994 8,578 8,578 2,732 2,732 217 217

Mar-Aug 1995Mar-Aug 1995 7,967 7,967 2,492 2,492 206 206

Sep 97-Feb 98Sep 97-Feb 98 6,953 6,953 2,233 2,233 165 165

Jul - Dec 2000Jul - Dec 2000 8,984 8,984 2,747 2,747 127 127

2. Trauma audit committee dead case peer review2. Trauma audit committee dead case peer review

Type Non Preventable PotentiallyPreventable

Preventable Total

No Dead % No Dead % No Dead % No Dead %

1994 89 76 85.4 75 59 87.7 2546 82 3.2 2710 217 8.0

1995 113 94 83.2 62 50 80.6 2317 62 2.7 2492 206 8.2

1998 106 99 93.3 35 23 65.7 2091 42 2.0 2232 164 7.3

2000 110 78 70.9 42 14 33.3 2595 35 1.3* 2747 127 4.6

* Statistical significant* Statistical significant

ResultsResultsResultsResults

3. Pitfall in the management of trauma patient3. Pitfall in the management of trauma patient

Year Type of Pitfall

Delay DxNo/C

ErrorDx

No/C

Error RxNo/C

ErrorTechnique

No/C

SystemInadequacy

No/C

TotalNo/C

1994 10/10 24/14 222/164 12/10 139/67 407/265

1995 13/9 8/7 172/136 19/15 89/50 301/217

1998 6/4 7/5 73/46 8/5 67/26 161/86*

2000 3/- 12/3 102/67 18/14 21/4 156/88

C = Contribute to deadC = Contribute to dead * = Statistic significant* = Statistic significant

ResultsResultsResultsResults

4. Performance Rate4. Performance Rate

KPI TotalNo

Yes % Threshold

1. In ER >2 hr 2638 55 2.1 0

2. Exceed 2000 cc V without blood 79 42 53.2 20

3. Explore penetrating wound > 1 hr of arrival 65 33 50.8 20

4. Spend time for CT > 1 hr 108 29 26.9 20

5. GCS < 13 no CT with in 4 hr 458 57 12.4 10

6. GCS < 9 intubution within 10 min 105 97 92.4 100

7. Multiple injury no CXR 283 52 18.4 20

ResultsResultsResultsResults

ResultsResultsResultsResults

KPI TotalNo

Yes % Threshold

8. Blunt injury above clavicle no C-spine XR 723 224 31.0 20

9. Blunt injury above clavicle no collar 674 190 28.2 20

10. Multiple injury no O2 278 11 4.0 0

11. Represent in ER within 72 hr 2683 11 0.4 0

12. Missed fracture 1428 6 0.4 0

13. Hypothermia 2681 2 0.1 0

14. Fracture fixation within 48 hr of arrival 950 791 83.7 80

4. Performance Rate4. Performance Rate

ResultsResultsResultsResults

KPI TotalNo

Yes % Threshold

15. Compound fracture fixation within 8 hr 439 117 26.7 80

16. Non therapeutic laparotomy 107 3 2.8 20

17. Time to craniotomy

< 2 hr 144 3 2.1

2 – 4 hr 144 23 16.0 80

>4 hr 144 118 81.9

18. Jt dislocation Rx > 4 hr 56 12 21.4 80

4. Performance Rate4. Performance Rate

4. Performance Rate4. Performance Rate

KPI TotalNo

Yes % Threshold

19. Laparotomy in PT with BP<90 in 60 min 32 7 21.9 80

20. Time to laparotomy

< 2 hr 144 49 43.0

2 – 4 hr 144 27 23.7 80

>4 hr 144 38 33.3

21. Rx ischemic limb in 4 hr 6 2 33.3 80

22. Unplanned return to OR 641 19 3.0 5

ResultsResultsResultsResults

ResultsResultsResultsResults

KPI TotalNo

Yes % Threshold

23. Unplanned return to ICU 48 2 4.2 5

24. Hct < 25% during admission 2603 15 5.8 10

25. Document T in OR 1612 1 0.1 80

26. All injury Dx in 24 hr 2671 2620 98.1 99

27. Complication 2683 267 10.0 10

4. Performance Rate4. Performance Rate

1. Establishing the KPIs for trauma care is a 1. Establishing the KPIs for trauma care is a major step in improving the quality of caremajor step in improving the quality of care

2. Key success is to make all personnel 2. Key success is to make all personnel understand and willing to practice the KPIsunderstand and willing to practice the KPIs

Discussion

Medical and Nursing Audit for the Management of Traumatic patient 1997-1998

Identifying Problem

Room for improvement of Preventable deathPs>0.5 MR 94=3.5% 95=2.8% 97=2.7%PV MR 94=3.2% 95=2.7% 97=2.1%

Understanding Cause

Completeness of audit filterCooperation of personnel

Establishing KPIEstablishing performancemanagement

ImplementationPs>0.5 MR 00=2.0%PV MR 00=1.3%

Suggesting SolutionImplementationEvaluation

Referral AuditReferral AuditReferral AuditReferral Audit

Result of Referral Development, Khon Kaen Hospital, Result of Referral Development, Khon Kaen Hospital, 1997-20001997-2000

Procedure Adequate Inadequate No

97 %

98 %

99 %

00 %

97 %

98 %

99 %

00 %

97 %

98 %

99 %

00 %

Airway 54.7 59.9 67.6 77.8 12.9 14.2 6.9 7.7 32.5 25.9 25.5 14.4

Stop bleeding

53.0 54.3 69.7 67.6 31.2 37.0 24.4 27.3 15.8 8.7 6.0 5.2

Splint 43.9 48.3 51.9 53.6 28.3 32.5 27.1 22.9 27.7 19.2 21.0 23.5

IV fluid 83.1 43.2 89.3 86.2 6.5 5.9 10.5 8.5 10.5 8.5 4.8 5.3

First Aid Care of EMT and VolunteerFirst Aid Care of EMT and VolunteerFirst Aid Care of EMT and VolunteerFirst Aid Care of EMT and Volunteer

Procedure Care No Care

Proper Improper

97

%

98

%

99

%

00

%

97

%

98

%

99

%

00

%

97

%

98

%

99

%

00

%

1. Volunteer

Airway care 1.1 0 0 9.1 2.9 7.2 5.3 0 90.0 92.8 94.7 90.9

Stop bleeding 4.5 2.5 5.5 13.2 9.8 7.0 7.4 9.6 85.7 90.5 87.1 77.2

Splint/slab 3.7 9.5 9.4 27.5 6.4 9.0 14.4 7.2 80.9 81.5 73.2 65.4

IV fluid 7.0 5.3 4.9 6.0 0.8 4.1 1.2 0 92.2 90.6 93.9 94.0

2. EMT

Airway care 30.2 33.3 70.0 68.3 7.0 11.1 0 4.9 62.8 55.6 30.0 26.8

Stop bleeding 23.3 37.2 45.5 63.9 22.5 15.4 14.7 12.0 54.2 47.4 39.8 24.0

Splint/slab 30.8 50.0 67.1 80.4 7.7 6.7 9.1 3.4 61.5 43.3 23.7 16.2

IV fluid 37.7 37.2 22.7 22.7 1.4 1.9 0 4.5 60.9 61.1 77.3 72.7

IS Table 31 IS Table 31 Number of Patient treated at ER >2 hr.Number of Patient treated at ER >2 hr.

IS Table 31 IS Table 31 Number of Patient treated at ER >2 hr.Number of Patient treated at ER >2 hr.

Year

Time

1997

No. (%)

1998

No. (%)

1999

No. (%)

2000

No. (%)

00.00-07.59 31 (8.7) 62 (9.1) 43 (3.9) 83 (7.1)

08.00-15.59 55 (7.2) 83 (5.9) 109 (4.7) 149 (6.2)

16.00-23.59 40 (4.8) 71 (4.5) 65 (2.6) 89 (3.5)

Total 126 (2.9) 216 (5.9) 217 (2.9) 321 (3.4)

Traffic Injury Cost classified by severity in 5 area based (2004)

Area basedBaht/case Baht/accident

Dead Disability Severe MinorProperty

damage

Average 3,395,551 3,617,150 122,591 30,247 40,161

Bangkok 6,191,330 6,322,792 253,689 135,471 128,300

Others (average of 4 regions) 3,241,150 3,548,514 115,933 23,181 31,145

North 2,602,575 2,789,470 114,661 23,030 31,081

Central 3,710,683 4,252,905 116,760 23,294 31,164

Northeast 2,553,037 2,725,961 114,991 23,058 31,184

South 3,364,576 3,602,481 116,202 23,191 31,067

Traffic Injury Cost classified by severity in 5 area based (2004)

Area Based

Dead Disability Severe Minor Property damage Total

Million baht %

Million baht %

Million baht %

Million baht %

Million baht %

Million baht %

Bangkok4,618.7

17.6 1,429.0 5.4 2,660.9 25.2 6,608.7 10.1 10,958.3 41.7 26,275.7 100

North 3,464.0 26.1 2,669.5 20.1 2,543.4 13.6 1,797.1 19.2 278.0 21.0 13,262.0 100

Central 24,260.4 34.5 16,650.1 23.7 10,596.4 10.6 7,436.3 15.1 11,431.8 16.2 70,375.1 100

North-east 9,173.1 26.0 6,994.8 19.8 6,840.8 13.7 4,825.4 19.4 7,501.8 21.2 35,335.9 100

South 6,883.9 29.7 5,299.3 22.8 396,074.0 12.0 2,780.6 17.1 4,282.1 18.5 23,206.6 100

Total 48,400.2 28.7 33,042.7 19.6 2,660,229.0 13.9 23,448.1 15.8 36,962.1 21.9 168,455.3 100

EFFECTIVE KNOWLEDGE TRANSFER EFFECTIVE KNOWLEDGE TRANSFER

REQUIRES THE RECIPIENT TO NOT ONLY REQUIRES THE RECIPIENT TO NOT ONLY

HAVE A NEED BUT ALSO A DESIRE TO HAVE A NEED BUT ALSO A DESIRE TO

MEET THAT NEED; IT NEEDS THEIR MEET THAT NEED; IT NEEDS THEIR

HEARTS AS WELL AS THEIR MINDS.HEARTS AS WELL AS THEIR MINDS.

B.J. Campbell, 1998B.J. Campbell, 1998

Global Traffic Safety TrustGlobal Traffic Safety Trust

Your Committee motivationdelication

to make to happen make a difference

Peter Davison