Vanderbilt University School of Medicine, Nashville, Tennessee.
Vanderbilt Division of Trauma and Surgical Critical Care, Nashville, Tennessee.
J Surg Educ. 2018 Nov;75(6):1551-1557. doi: 10.1016/j.jsurg.2018.03.014. Epub 2018 Apr 12.
Trauma patients are triaged by the severity of their injury or need for intervention while en route to the trauma center according to trauma activation protocols that are institution specific. Significant research has been aimed at improving these protocols in order to optimize patient outcomes while striving for efficiency in care. However, it is known that patients are often undertriaged or overtriaged because protocol adherence remains imperfect. The goal of this quality improvement (QI) project was to improve this adherence, and thereby reduce the triage error. It was conducted as part of the formal undergraduate medical education curriculum at this institution.
A QI team was assembled and baseline data were collected, then 2 Plan-Do-Study-Act (PDSA) cycles were implemented sequentially. During the first cycle, a novel web tool was developed and implemented in order to automate the level assignment process (it takes EMS-provided data and automatically determines the level); the tool was based on the existing trauma activation protocol. The second PDSA cycle focused on improving triage accuracy in isolated, less than 10% total body surface area burns, which we identified to be a point of common error. Traumas were reviewed and tabulated at the end of each PDSA cycle, and triage accuracy was followed with a run chart.
This study was performed at Vanderbilt University Medical Center and Medical School, which has a large level 1 trauma center covering over 75,000 square miles, and which sees urban, suburban, and rural trauma.
The baseline assessment period and each PDSA cycle lasted 2 weeks. During this time, all activated, adult, direct traumas were reviewed. There were 180 patients during the baseline period, 189 after the first test of change, and 150 after the second test of change. All were included in analysis.
Of 180 patients, 30 were inappropriately triaged during baseline analysis (3 undertriaged and 27 overtriaged) versus 16 of 189 (3 undertriaged and 13 overtriaged) following implementation of the web tool (p = 0.017 for combined errors). Overtriage dropped further from baseline to 10/150 after the second test of change (p = 0.005). The total number of triaged patients dropped from 92.3/week to 75.5/week after the second test of change. There was no statistically significant change in the undertriage rate.
The combination of web tool implementation and protocol refinement decreased the combined triage error rate by over 50% (from 16.7%-7.9%). We developed and tested a web tool that improved triage accuracy, and provided a sustainable method to enact future quality improvement. This web tool and QI framework would be easily expandable to other hospitals.
创伤患者在根据创伤激活协议被送往创伤中心的途中，根据其损伤的严重程度或对干预的需求进行分诊。大量研究旨在改进这些方案，以优化患者预后，并努力提高护理效率。然而，已知患者经常被分诊不足或分诊过度，因为协议的遵守仍然不完美。该质量改进（QI）项目的目标是提高这种依从性，从而减少分诊错误。它是作为该机构正式本科医学教育课程的一部分进行的。
组建了一个 QI 团队并收集了基线数据，然后顺序实施了 2 个计划-执行-研究-行动（PDSA）循环。在第一个循环中，开发并实施了一个新的网络工具，以便自动进行级别分配过程（它采用 EMS 提供的数据并自动确定级别）；该工具基于现有的创伤激活协议。第二个 PDSA 循环侧重于提高孤立的、总表面积小于 10%的烧伤的分诊准确性，我们发现这是一个常见错误点。在每个 PDSA 循环结束时，对创伤进行回顾和制表，并使用运行图跟踪分诊准确性。
这项研究在范德比尔特大学医学中心和医学院进行，该中心拥有一个大型一级创伤中心，覆盖超过 75000 平方英里，服务于城市、郊区和农村创伤。
基线评估期和每个 PDSA 循环持续两周。在此期间，回顾所有激活的成人直接创伤。基线期有 180 名患者，第一次测试变更后有 189 名，第二次测试变更后有 150 名。所有患者均纳入分析。
在基线分析中，有 30 名患者被不恰当地分诊（3 名分诊不足，27 名分诊过度），而在网络工具实施后，有 16 名患者（3 名分诊不足，13 名分诊过度）（p = 0.017，综合错误）。第二次测试变更后，分诊过度从基线时的 10/150 进一步下降（p = 0.005）。第二次测试变更后，分诊患者总数从每周 92.3 人下降至每周 75.5 人。分诊不足率没有统计学意义的变化。
网络工具的实施和方案的细化相结合，将综合分诊错误率降低了 50%以上（从 16.7%降至 7.9%）。我们开发并测试了一种网络工具，该工具提高了分诊的准确性，并提供了一种可持续的方法来实施未来的质量改进。该网络工具和 QI 框架很容易扩展到其他医院。
