CLINICAL CASE REVIEWQUALITY ASSESSMENT

PREVENTABLE DEATH MODEL

Stuart Reynolds, MD

QUALITY ASSURANCE

PHILOSOPHY HOSPITAL REGIONAL

QUALITY ASSESSMENT

QAQA QIQI PICPIC 10 STEP10 STEP FADEFADE IMPROVEIMPROVE PDCAPDCA TQMTQM TQITQI PIPI

REALITY

• TRAUMA IS• SURGICAL DISEASE• MULTIDISCIPLINARY

• MEDICAL• PROCESSES

REALITY

• TRAUMA CARE ASSESSMENT• INCLUDES THE SYSTEM• MULTIDISCIPLINARY

QA/QI PROCESS

A TOOL OPPORTUNITY FOR IMPROVEMENT BAD APPLES TEAM GOOD OUTCOME BAD OUTCOME

PURPOSE

BLAME---NO TARGET PHASE, PROVIDER---NO IMPROVE SYSTEM---YES IMPROVE PATIENT CARE---YES COMPARE---YES

FOCI

SYSTEMS ISSUES PROCESSES CLINICAL CARE

EQUITABLE

HOSPITAL

TRAUMA PROGRAM AUTHORITY REGISTRY IDENTIFIERS/SYSTEM

PREVENTABLE MORTALITY STUDIES

URBAN AUTOPSY PANEL

RURAL PREVENTABLE MORTALITY STUDY

URBAN/RURAL PREVENTABLE MORTALITY INAPPROPRIATE CARE RESOURCE UTILIZATION

MONTANA RPMS 1990

PREVENTABLE 13% HOSPITAL PREVENTABLE 27% INAPPROPRIATE CARE ED 68%

MONTANA RPMS 1998

PREVENTABLE 8% HOSPITAL PREVENTABLE 15% INAPPROPIATE CARE ED 40%

INTERESTING FINDINGS

DELAY IN DISCOVERY LONG TRANSPORT BLS (VOLUNTEER) PREHOSPITAL RURAL/URBAN NON-SYSTEM

SCOPE OF STUDY

GEOGRAPHY TIME FRAME NUMBER OF DEATHS

PANEL

TRAUMA SURGEONS EMERGENCY PHYSICIANS ED NURSING FLIGHT SERVICE PREHOSPITAL ALS/BLS CONSULTANTS PRIMARY/SECONDARY REVIEWERS

SOURCES OF DATA

DEATH CERTIFICATE AMBULANCE TRIP REPORT HOSPITAL MEDICAL RECORD AUTOPSY REPORT INVESTIGATIVE REPORTS

CORONERLAW ENFORCEMENTFARS

CHALLENGES

DIVERGENT DATA SOURCES INCONSISTENT COMPLETENESS AND

ACCURACY VOLUNTARY DATA SUBMISSION CONFIDENTIALITY CONCERNS DESIGN REQUIREMENTS

CHART REVIEW PROCESS

NOT DOCUMENTED, NOT DONE DOCUMENTED

DX SEQUENCE

AVOID TUNNEL VISION NO PREJUDICE SYSTEMATIC

ABSTRACTS/CHECK LIST

GLOBAL VIEW DECISIONS REGARDING CARE

– AFTER COMPLETE REVIEW

DATA SOURCES

REGISTRY TRAFFIC REPORTS CORONER REPORT AUTOPSY

PREHOSPITAL EMS

TIMES EVALUATION INTERVENTIONS/PROTOCOLS NARRATIVES INTERHOSPITAL TRANSFER

ED TRAUMA FLOW SHEET

THE IDEAL RESPONSE/RX TIMES DIAGNOSTIC TESTS INTERVENTIONS SEQUENCE

HOSPITAL RECORDS

H&P CONSULTATIONS NURSING NOTES

NARRATIVE

MIS

DISCHARE SUMMARY

OR RECORD/OP REPORT

TIMES PROCEDURES VITAL SIGNS/INITIAL OPERATION NUMBER/TIMING OF OPERATIONS

INTENSIVE CARE UNIT

APPROPRIATE RX/MONITORING WHO CARES FOR THE PATIENT

ANCILLARY

APPROPRIATE STUDIES APPROPRIATE RESPONSE QUALITY/TIMELINESS OF REPORTS

PREVENTABILITY

ACS GUIDELINES– FRANKLY PREVENTABLE– POSSIBLY PREVENTABLE– NON PREVENTABLE

CARE INAPPROPRIATE

ATLS/PHTLS GUIDELINES ACLS PROTOCOLS FUTILE RECUSSITATION

RESOURCE UTILIZATION

PRESERVE SYSTEM RESPONSE INAPPROPRIATE COST

PREVENTABLE DEATH STUDIES

REGIONAL/STATE NATIONAL GUIDELINES SYSTEM FUNCTION NOT PUNATIVE