Trauma

Introduction

This topic is intended to help anyone who is interested in quality improvement surrounding Trauma.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

Radiographic Stewardship

American College of Surgeons

Protocol

University of Rochester

Unnecessary computed tomography (CT) scanning increases health care costs and places children at increased risk of fatal cancers. We aimed to reduce unnecessary CT imaging in pediatric blunt trauma patients. Imaging algorithms (guidelines) were developed and retrospectively validated for efficacy and safety. Institutional buy in was generated by validating the guidelines retrospectively for efficacy and safety and getting feedback from stakeholders.

Education was provided to staff, including trainees, regarding purpose and usage of the tools. Algorithms were then implemented prospectively to guide management for traumatically injured children. Periodic chart review was performed to identify imaging practices (outcome measure) and missed injuries (balancing measure). Repeated Plan, Do, Study, Act (PDSA) cycles were carried out to improve compliance.

Protocols

Resources

  • CT reduction in trauma abstract
  • validating algorithms abstract
  • data collection sheet Sample file used at the University of Rochester to denote what imaging was performed and what was indicated for each pediatric trauma patient. This allows us to track our data over time
  • IRB protocol

Stakeholders: pediatric blunt trauma victims, pediatric trauma team, pediatric emergency department (ED), pediatric radiology, orthopedic surgery, neurosurgery, pediatric intensive care, hospital leadership, malpractice insurer
Folder Content:

Presentations: Sample presentation given to stake holders (in this case surgical
residents) to provide and update and get buy in for the imaging reduction QI initiative.

Challenges and solutions

  1. Challenge: Changing the culture in the ED from pan-scanning to selectively scanning based on mechanism, signs, symptoms and other data (lab and radiographic). Solution: Meeting with all stakeholders and addressing their concerns. Meeting with the ED and surgical residents and explaining the rationale for the change in practice. The attached presentation and update was used to educate the residents and ED staff about the project. We also used this time to listen to and address their concerns which likely improved buy in.
  2. Challenge: Getting providers easy access to the guidelines. Solution: Widespread dissemination in the ED and to surgical residents. Creating an electronic web based calculator
  3. Challenge: Building in a process measure to determine if the guidelines are being used. Solution: A web calculator was built that can track when the online version of the guideline was used. We are looking into building a pediatric trauma imaging order set with a prompt and link to the guidelines before ordering CT scans.

Submitted by Derek Wakeman

References

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  2. Arbra CA, Vogel AM, Plumblee L, et al. External validation of a five-variable clinical prediction rule for identifying children at very low risk for intra-abdominal injury after blunt abdominal trauma. J Trauma Acute Care Surg. 2018;85(1):71-77.  [PMID:29659473]
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Last updated: May 7, 2019