catherine truchon - cadth
TRANSCRIPT
2017 CATDH Symposium
Catherine Truchon, Ph.D., MSc. Adm.
Coordinator and Principal Scientist Trauma and Critical Care Unit INESSS
The Quebec Trauma Care Continuum: When setting standards and assessing performance meet with quality improvement
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Background history
Prior to 1990, the mortality rate from severe trauma was over 52% in Québec November 1989: Death of the athlete Victor Davis December 1989: Shooting at École Polytechnique
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Trauma Care Continuum
Accessibility Continuity Efficacy Quality of services
MSSS SAAQ
The Trauma Care Continuum (TCC)
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Trauma Care Continuum
Build the system and evaluate it…continuously
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Donabedian model
STRUCTURE PROCESS OUTCOMES
Clear mandates
Commitment
Transfer protocoles
Coordination structures
Resources
Procedures
Clinical protocols
Communication processes
Quality improvement mechanisms
Better survival
Lower morbidity
Social reintegration
Quality of life
Lower costs
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An integrated trauma network
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An integrated trauma network
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Monitoring compliance quality and performance
STRUCTURE PROCESS OUTCOMES
COMPLIANCE ASSESSMENT
QUALITY AND PERFORMANCE MEASUREMENT
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Compliance assessment: Structure indicators
Transfer and contingency standing agreements Local and regional governing and quality-
improvement committees
Quality improvement action plans
Staffing
Facilities and equipment
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REQUIRED PROTOCOLS Yes / No Revision date Location Procédure pour le préavis du SPU avec description du rôle de chacun des intervenants et du mécanisme de collecte de données (y inclus une communication directe entre le médecin à l’urgence et le personnel ambulancier) Procédure de mise en tension à trois niveaux avec description du rôle de chacun des intervenants Procédure de mise en tension avec description du rôle de chacun des intervenants
Procédure d’intubation difficile avec algorithme
Procédure pour l’hémopéritoine avec algorithme
Procédure pour l’échographie à l’urgence respectant le marqueur M30
Procédure pour accès veineux avec algorithme médical et infirmier
Procédure pour la stabilisation d’une fracture complexe du bassin avant le transfert
Procédure de prise en charge d’une patiente traumatisée enceinte
Procédure de prise en charge d’un traumatisé pédiatrique respectant les corridors de transfert établis
Procédure pour l’antibiothérapie prophylactique dans le cas d'une fracture ouverte
Procédure pour la prise en charge d’un patient présentant un traumatisme pénétrant à la région cervicale
Procédure de clairance de la colonne cervicale
Procédure de prise en charge avant transfert d’un patient présentant un traumatisme craniocérébral modéré ou grave (TCCMG) Procédure de dépistage et de gestion du risque de complications médicales graves pour les patients ayant subi un TCCL
Procédure pour le maintien de la normothermie du patient
Procédure pour la détection du syndrome compartimental
Procédure pour la décontamination d’un patient (biologique, chimique, nucléaire, radiologique)
Procédure d’accompagnement pour le déplacement interne du patient
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Compliance Assessment
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Quality and performance assessment
STRUCTURE PROCESS
MORTALITY
UNPLANNED READMISSIONS
LENGTH OF STAY
COMPLICATIONS
13 PROCESS INDICATORS
12 OUTCOME INDICATORS
QUALITY AND PERFORMANCE ASSESSMENT
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Process and outcome indicators
Sources: Internet (Ex. Trauma systems, Professional associations) PUBMED, EMBASE, etc.
Selection criteria: Supporting evidence Used by at least 2 other trauma systems Consensus amongst expert panel
Statistical adjustments for patient status on arrival (age, comorbidity, etc.)
Provincial average for each indicator
Gap analysis for each facility
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13 Process Indicators
PI 1 Transfer of patients with open/depressed skull fracture initially received in level III/IV centre to level I/II centre
PI 2 Transfer of spinal injury patients to acute spinal centre PI 3 Reduce dislocation of major joint in <1h PI 4 Airway secured in ED for GCS <9 PI 5 Stabilize/embolize unstable pelvic fracture PI 6 Open long bone fracture surgery <6h PI 7 Fractured femur surgery <24h (femoral shaft fractures) PI 8 Transfer to ICU or Surgery <1h PI 9 Deaths >1 h after arrival occur on ward (not in ED) PI 10 ED stay <4h for patients with ISS≥15 PI 11 Delay for abdominal, thoracic, brain surgery <24h PI 12 No reintubation within 48 h after extubation PI 13 Prophylactic antibios for open fractures
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12 outcomes indicators
OI 1 Adjusted mortality rate
OI 2 Adjusted mortality rate for > 65 years
OI 3 Adjusted mortality rate for ISS> 15
OI 4 Adjusted complications
OI 5 Adjusted complications for > 65 years
OI 6 Adjusted complications for ISS> 15
OI 7 Adjusted unplanned acute care readmissions
OI 8 Adjusted unplanned acute care readmissions for > 65 years
OI 9 Adjusted unplanned acute care readmissions for ISS> 15
OI 10 Adjusted LOS
OI 11 Adjusted LOS for > 65 years
OI 12 Adjusted LOS for ISS> 15
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SIRTQ: Quebec Trauma Registry
• All 59 acute trauma facilities
• SIRTQ exploited since 1998
• All trauma admissions > 24 hrs
• N = 20,000/year
• Continuous access to data by INESSS
• Linkage to MEDECHO and Fichier des décès
• Others to come
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Quality and performance reports
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Local and comparative descriptive statistics
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OI 10 – Length of stay in ER < 4 hrs
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Adjusted mortality rate
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Complications in severe traumas (ISS > 15)
2007-2012 2012-2015
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Quality and performance report analysis by local trauma committees
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OVERALL RESULTS
1992 Fall in the MORTALITY RATE of severe trauma from 52% to 8.6%
1999
Additional 24% decrease in the mortality rate from all trauma (all levels of severity)
2012 A 16% decrease in length of stay - LOS (with no impact on the complication or readmission rates)
200 extra lives saved
per year
2002
Institution of TCC
Savings of $6.3M / year
Liberman et al., 2004, Journal of Trauma, Vol. 56 Moore et al., Journal of Surgery, 2015, Vol. 39
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OVERALL RESULTS
2006-2012 Period Province of Quebec has the lowest adjusted mortality rate in Canada
Actuarial study by the SAAQ (2006)
Estimated savings of $3 billion since 1992
Publications: Lynne Moore et al., 2016, 2015 etc.
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KEY INGREDIENTS
• Integrated long-term vision • Quality evaluation embedded early on • Strong network structure • Balanced compliance and performance
assessment • Gradual educative approach • Structured and supported feedback
and accountability processes
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Challenges and Strategies
• Quebec’s BIG healthcare network reconfiguration • Other evolving priorities and issues (aging, stroke, etc.) • Accountability model is complex and demanding
• Emphasis on key elements of the compliance monitoring process • Better shared responsibilities (ministry, facilities, INESSS and others) • Expand indicator monitoring to reach issues related to costs, efficiency,
quality of life, return to productivity, etc. • Reduce Trauma Registry requirements • Better support network with tools, protocols, clinical practice
guidelines
inesss.qc.ca [email protected]
2535, boulevard Laurier, 5e étage
Québec (Québec) G1V 4M3
2021, avenue Union, bureau 10.083 Montréal (Québec) H3A 2S9
MERCI !
Special thanks to the entire Trauma and Critical Care Unit at INESSS, our predecessors, past and current collaborators
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Transfer of spinal cord injuries (SCI) to SCI Centers of expertise
1998-2006 2007-2012 2013-2016
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1998-2006 2007-2012 2013-2016