Evaluating trauma center process performance in an integrated trauma system with registry data

Abstract

Background: The evaluation of trauma center performance implies the use of indicators that evaluate clinical processes. Despite the availability of routinely collected clinical data in most trauma systems, quality improvement efforts are often limited to hospital-based audit of adverse patient outcomes.

Objective: To identify and evaluate a series of process performance indicators (PPI) that can be calculated using routinely collected trauma registry data.

Materials and methods: PPI were identified using a review of published literature, trauma system documentation, and expert consensus. Data from the 59 trauma centers of the Quebec trauma system (1999, 2006; N = 99,444) were used to calculate estimates of conformity to each PPI for each trauma center. Outliers were identified by comparing each center to the global mean. PPI were evaluated in terms of discrimination (between-center variance), construct validity (correlation with designation level and patient volume), and forecasting (correlation over time).

Results: Fifteen PPI were retained. Global proportions of conformity ranged between 6% for reduction of a major dislocation within 1 h and 97% for therapeutic laparotomy. Between-center variance was statistically significant for 13 PPI. Five PPI were significantly associated with designation level, 7 were associated with volume, and 11 were correlated over time.

Conclusion: In our trauma system, results suggest that a series of 15 PPI supported by literature review or expert opinion can be calculated using routinely collected trauma registry data. We have provided evidence of their discrimination, construct validity, and forecasting properties. The between-center variance observed in this study highlights the importance of evaluating process performance in integrated trauma systems.

Keywords: Clinical processes; performance indicators; quality of care; trauma system.

Figure 1

Percent conformity with PPI #1 “transfer of TBI patients with GCS ≤12 initially received in level III/IV center to a level I/II center”

Figure 2

Percent conformity with PPI #5 “protection of airway in the emergency department for patients with a glasgow coma score <9”

Figure 3

Percent conformity with PPI #12 “emergency department stay <4 h in patients with ISS ≥15”