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The Trauma Quality Improvement Program: Pilot Study and Initial Demonstration of Feasibility

Hemmila, Mark R. MD; Nathens, Avery B. MD, PhD; Shafi, Shahid MD, MPH; Calland, J. Forrest MD; Clark, David E. MD, MPH; Cryer, H. Gill MD, PhD; Goble, Sandra MS; Hoeft, Christopher J. BS; Meredith, J. Wayne MD; Neal, Melanie L. MS; Pasquale, Michael D. MD; Pomphrey, Michelle D. RN; Fildes, John J. MD

The Journal of Trauma: Injury, Infection, and Critical Care: February 2010 - Volume 68 - Issue 2 - p 253-262
doi: 10.1097/TA.0b013e3181cfc8e6
Original Articles
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Objective: The American College of Surgeons Committee on Trauma has created a “Trauma Quality Improvement Program” (TQIP) that uses the existing infrastructure of Committee on Trauma programs. As the first step toward full implementation of TQIP, a pilot study was conducted in 23 American College of Surgeons verified or state designated Level I and II trauma centers. This study details the feasibility and acceptance of TQIP among the participating centers.

Methods: Data from the National Trauma Data Bank for patients admitted to pilot study hospitals during 2007 were used (15,801 patients). A multivariable logistic regression model was developed to estimate risk-adjusted mortality in aggregate and on three prespecified subgroups (1: blunt multisystem, 2: penetrating truncal, and 3: blunt single-system injury). Benchmark reports were developed with each center's risk adjusted mortality (expressed as an observed-to-expected [O/E] mortality ratio and 90% confidence interval [CI]) and crude complication rates available for comparison. Reports were deidentified with only the recipient having access to their performance relative to their peers. Feedback from individual centers regarding the utility of the reports was collected by survey.

Results: Overall crude mortality was 7.7% and in cohorts 1 to 3 was 16.4%, 12.4%, and 5.1%, respectively. In the aggregate risk-adjusted analysis, three trauma centers were low outliers (O/E and 90% CI <1) and two centers were high outliers (O/E and 90% CI >1) with the remaining 18 centers demonstrating average mortality. Challenges identified were in benchmarking mortality after penetrating injury due to small sample size and in the limited capture of complications. Ninety-two percent of survey respondents found the report clear and understandable, and 90% thought that the report was useful. Sixty-three percent of respondents will be taking action based on the report.

Conclusions: Using the National Trauma Data Bank infrastructure to provide risk-adjusted benchmarking of trauma center mortality is feasible and perceived as useful. There are differences in O/E ratios across similarly verified or designated centers. Substantial work is required to allow for morbidity benchmarking.

From the Department of Surgery (M.R.H.), University of Michigan Health System, Ann Arbor, Michigan; Department of Surgery (A.B.N.), University of Toronto, Toronto, Ontario, Canada; Department of Surgery (S.S.), Baylor Health Care System, Grapevine, Texas; Department of Surgery (J.F.C.), University of Virginia, Charlottesville, Virginia; Department of Surgery (D.E.C.), Maine Medical Center, Portland, Maine; Department of Surgery (H.G.C.), University of California Los Angeles Medical Center, Los Angeles, California; the American College of Surgeons (S.G., C.J.H., M.L.N.), Committee on Trauma, Chicago, Illinois; Department of Surgery (J.W.M.), Wake Forest University, Winston-Salem, North Carolina; Department of Surgery (M.D.P.), Lehigh Valley Hospital, Lehigh, Pennsylvania; Department of Surgery (M.D.P.), University of Virginia, Charlottesville, Virginia; and Department of Surgery (J.J.F.), University of Nevada, Las Vegas, Nevada.

Submitted for publication September 24, 2009.

Accepted for publication December 15, 2009.

This work was supported by National Institutes of Health grant K08-GM078610 with joint support from the American College of Surgeons and the American Association for the Surgery of Trauma (to M.R.H.) and by a Canada Research Chair in Systems of Trauma Care (to A.B.N.).

Presented at the 68th Annual Meeting of the American Association for the Surgery of Trauma, October 1–3, 2009, Pittsburgh, Pennsylvania.

Reprints: Mark R. Hemmila, MD, Trauma Burn Center, University of Michigan Health System, 1B407 University Hospital, 1500 E. Medical Center Drive, SPC 5033, Ann Arbor, MI 48109-5033; email: mhemmila@umich.edu.

© 2010 Lippincott Williams & Wilkins, Inc.