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

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


1
Tool that might be used to improve the trauma
system in the region
  • Witaya Chadbunchachai
  • Trauma and Critical Care Center
  • Khon Kaen Regional Hospital

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landslide
Thailand risk area
Risk chance
earthquake
Industrial hazard
terrorism
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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

7
  • It couldnt happen to us
  • is an un acceptable excuse for being ill
    prepared to deal with a major incident.
  • T.J. Hodgetts
  • K. Mackway-Jones
  • ????????????? ???????????????????????????????????
    ?????????
  • ???????????????????????????????????????????
  • ?????????????????????????????????????????????????

8
Development Frame An Inclusive Trauma Care
System
  • PREVENTION
  • TRAINING
  • EVALUATION

SYSTEM DEVELOPMENT
Major Trauma Patients
All Injured Patients
LEADERSHIP
  • PREHOSPITAL
  • Communication
  • Medical Direction
  • Triage
  • Transport

INTERFACILITY TRANSFER
ACUTE CARE FACILITY WITHIN A TRAUMA SYSTEM other
injured patients
TRAUMA CENTER most severity injured
or SPECIALTY CARE FACILITY peds, burns, and so on
LEGISLATION
FINANCE
REHABILITATION
Health Resources and Services Administration,
U.S. Department of Health and Human Services,
Rockville, MD, 1992
9
Trauma Registry System
Khon Kaen Hospital
10
Trauma Registry
  • Objective
  • To establish data base to monitor and modify
    trauma care system
  • To define nature and extend of trauma for
    prevention
  • To define factors for patients mortality and
    morbidity
  • To determine manpower requirement
  • To estimate expenditures

11
Ideal Character of Injury Surveillance System
  • 1. Usefulness
  • 2. The quality of surveillance
  • Simplicity
  • Flexibility
  • Acceptability
  • Sensitivity
  • Positive predictive value
  • Representative
  • Timeliness

12
Ideal Character of Injury Surveillance System
  • 3. Validation of Data Collection Methods
  • 4. Reliability of The Coding System

13
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

14
Work site at Registration Unit
15
Work site at ER
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Work site at ER
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Minimal Basic Data Set Modified from Text Book
of Trauma Champion Feliciano Chapter 2 Trauma
Scoring
19
American College of Surgeon
  • 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

20
American 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

21
Data Recording Form
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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 Occupational Injury ? 1 Yes ? 0 No ? Unknown Occupational Injury ? 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 Risk behaviors Risk behaviors
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 1. Alcohol ? 1 Use ? 0 Not use ? Unknown 1. Alcohol ? 1 Use ? 0 Not use ? Unknown 3. Seat belt ? 1 Use ? 0 Not use ? 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 2. Drugs/ Medication ? 1 Use (Specified) .. ? 0 Not use ? Unknown 2. Drugs/ Medication ? 1 Use (Specified) .. ? 0 Not use ? Unknown 4. Helmet ? 1 Use ? 0 Not use ? Unknown
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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 First aid / care while transport First aid / care while transport
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 Breathing care ? 1 Yes-appropriate ? 2 Yes but not appropriate ? 3 Not needed ? 0 No 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
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 Splint / Slab ? 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 . / min Consciousness description............................................................................................... Coma Scale .......................................... 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 . / min Consciousness description............................................................................................... Coma Scale .......................................... Type of injury cause ? 1 Blunt ? 2 Penetrating ? 3 Blunt and penetrating ? Others 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 . 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 . 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 . 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..(BRAIS..) 4...(BRAIS..) 2..(BRAIS..) 5...(BRAIS..) 3..(BRAIS..) 6...(BRAIS..) DIAGNOSIS (Specified organ and injury in detail) If admitted, do not fill at ER. 1..(BRAIS..) 4...(BRAIS..) 2..(BRAIS..) 5...(BRAIS..) 3..(BRAIS..) 6...(BRAIS..) DIAGNOSIS (Specified organ and injury in detail) If admitted, do not fill at ER. 1..(BRAIS..) 4...(BRAIS..) 2..(BRAIS..) 5...(BRAIS..) 3..(BRAIS..) 6...(BRAIS..) DIAGNOSIS (Specified organ and injury in detail) If admitted, do not fill at ER. 1..(BRAIS..) 4...(BRAIS..) 2..(BRAIS..) 5...(BRAIS..) 3..(BRAIS..) 6...(BRAIS..)
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 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 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 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
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Fourth Phase (1999)
Data collection by ER nurse And trauma center
clerk
Trauma Patients
Immediate key in on scene at ER By trauma center
clerk
Discharge
Admit
Summarized form for Dx, BR, AIS and key in
by trauma center nurse at Trauma Center Office
Analysis by IS output program and trauma center
programmer
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Documents
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Number of Injury Classified by Type
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Number of Dead Classified by Type
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Age and Sex of Injury 2005
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Type of External Cause of Injury 2005
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Organ Injury of the Admitted Case 2005
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Dead of Organ Injury and External Cause of
Injury 2005
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Day in Week of Injury 2005
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Time of Arrival 2005
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Utility of trauma registry
  • Traffic Injured Patients Data for Insurances
    Office every morning
  • Public Service
  • Trauma Auditing
  • Medical Audit
  • Nursing Audit
  • Referral Audit
  • EMS Audit
  • ER Audit

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Utility of trauma registry
  • Trauma prevention
  • Provincial Safety Committee review situation
    monthly
  • Medical Institute for Injury and Disaster
  • Epidemiology Department MOPH
  • Monitoring
  • Study and Research

39
THE UTILIZATION OF DATA FROM TRAUMA REGISTRY FOR
TRAUMA CARE IMPROVEMENT
40
  • Ps 1/1e-b
  • Ps Probability for survival
  • e 2.7183 (base on Napierian logarithms)
  • b b0b1(RTS)b2(ISS)b3(A)
  • RTS Revised Trauma Score
  • ISS Injury Severity Score
  • A 1 if age gt54
  • 0 if age lt54

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  • 1. GCS
  • 2. Blood pressure
  • 3. Respiratory rate
  • ISS
  • Age
  • 6. Mechanism of injury

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Recent Application
  • Trauma Auditing
  • Medical Audit
  • Nursing Audit
  • Referral Audit
  • EMS Audit
  • ER Audit

43
MEDICAL AUDIT
The technique to assess the quality of care
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  • Trauma registry
  • Medical record
  • Trauma audit recording form
  • Guideline for recording data and definition
  • Peer group review

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  • Leader
  • Peer group
  • Surgeon
  • Neuro Surgeon
  • CVT
  • Anesthetist
  • Orthopedist
  • Coordinator

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  • Set up committee
  • Set up the content for audit
  • Set up the coordinator
  • Committee meeting
  • Design the time, date, place for review
  • Peer group review
  • Analyze and report

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Before Audit Filter Application
Ps Number Death Percent
0.00-0.25 89 80 89.9
gt0.25-0.50 75 49 65.3
gt0.50-1.00 2,546 88 3.5
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Before Audit Filter Application
Type of Mortality Number Death
Non-preventable death 85 76 89.4
Potentially preventable death 85 59 69.4
Preventable death 2,540 82 3.2
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Study on Performance Following the Key
Performance Indicator for Trauma Care Khon Kaen
Hospital
  • Witaya Chadbunchachai
  • Trauma and Critical Care Center
  • Khon Kaen Hospital

57
Conceptual Frame Work
  • Set up system of medical care quality assessment
  • Auditing system - dead case peer review
  • Set up audit filter
  • Implementation
  • Evaluation

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Problems in Previous Projects
  • Completeness of audit filter
  • Cooperation of personnel

KPIs enhanced the efficiency of trauma care.
Copes J. Trauma
199538432-438
59
Performance Indicator
- Statistic that reflected the quality of
care process leading to outcomes.
Performance Management
- Method that manages personnel to comply
with KPIs.
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Objectives
  • Establishing the KPIs for trauma care
  • Establishing the Performance Management System
    for personnel in trauma care to comply with KPIs

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Method
1. Preparation
  • KPIs establishment
  • Committee making KPIs
  • Review by 3 experts
  • System for performance management
  • Computer program for collecting data
  • Collecting data team
  • Various form

(March - April 2000)
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Method
2. Implementation
  • Meeting and training
  • CME
  • Morning report
  • Case conference
  • MM conference
  • X-ray conference
  • Orientation
  • Solving problem of system inadequacy

(May - June 2000)
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Method
3. Outcome Study
Inclusion - all trauma admission - all
trauma dead Exclusion - underlying
disease Evaluation - Preventable dead rate -
Performance rate - Compare result with 1995,
1998
(July - December 2000)
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Method
4. Analysis
(January - June 2001)
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Results
1. Number of trauma patients
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Results
2. Trauma audit committee dead case peer review
Statistical significant
67
Results
68
Results
4. Performance Rate
69
Results
4. Performance Rate
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Results
4. Performance Rate
71
Results
4. Performance Rate
72
Results
4. Performance Rate
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1. Establishing the KPIs for trauma care is a
major step in improving the quality of care
2. Key success is to make all personnel
understand and willing to practice the KPIs
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Medical and Nursing Audit for the Management of
Traumatic patient 1997-1998
Identifying Problem
Understanding Cause
Room for improvement of Preventable death Psgt0.5
MR 943.5 952.8
972.7 PV MR 943.2
952.7 972.1

Completeness of audit filter Cooperation of
personnel
Establishing KPI Establishing performance manageme
nt
Implementation
Psgt0.5 MR 002.0 PV MR 001.3
Suggesting Solution
Implementation
Evaluation
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Referral Audit
Result of Referral Development, Khon Kaen
Hospital, 1997-2000
Procedure Adequate Adequate Adequate Adequate Inadequate Inadequate Inadequate Inadequate No No No No
Procedure 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
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First Aid Care of EMT and Volunteer
Procedure Care Care Care Care Care Care Care Care No Care No Care No Care No Care
Procedure Proper Proper Proper Proper Improper Improper Improper Improper No Care No Care No Care No Care
Procedure 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
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IS Table 31 Number of Patient treated at ER gt2
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)
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Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004)
Area based Baht/case Baht/case Baht/case Baht/case Baht/accident
Area based Dead Disability Severe Minor Property 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
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Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004) Traffic Injury Cost classified by severity in 5 area based (2004)

Area Based Dead Dead Dead Disability Disability Disability Severe Severe Severe Minor Minor Minor Property damage Property damage Property damage Total Total Total
Area Based Million baht Million baht Million baht Million baht Million baht Million baht
Bangkok 4,618.7 17.6 17.6 1,429.0 5.4 5.4 2,660.9 25.2 25.2 6,608.7 10.1 10.1 10,958.3 41.7 41.7 26,275.7 100 100
North 3,464.0 26.1 26.1 2,669.5 20.1 20.1 2,543.4 13.6 13.6 1,797.1 19.2 19.2 278.0 21.0 21.0 13,262.0 100 100
Central 24,260.4 34.5 34.5 16,650.1 23.7 23.7 10,596.4 10.6 10.6 7,436.3 15.1 15.1 11,431.8 16.2 16.2 70,375.1 100 100
North- east 9,173.1 26.0 26.0 6,994.8 19.8 19.8 6,840.8 13.7 13.7 4,825.4 19.4 19.4 7,501.8 21.2 21.2 35,335.9 100 100
South 6,883.9 29.7 29.7 5,299.3 22.8 22.8 396,074.0 12.0 12.0 2,780.6 17.1 17.1 4,282.1 18.5 18.5 23,206.6 100 100
Total 48,400.2 28.7 28.7 33,042.7 19.6 19.6 2,660,229.0 13.9 13.9 23,448.1 15.8 15.8 36,962.1 21.9 21.9 168,455.3 100 100
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