Quality management in the early care of patients with multiple injuries: Documentation of treatment and review of quality of care

Abstract

Quality management in early clinical care of patients with multiple injuries (description of actual process, identification of problems, implementation of quality improvement) is not possible without sufficient baseline data about the present situation of medical treatment. This study investigates whether the current documentation of treatment in the emergency room is appropriate to judge upon the quality of the process and to detect problems. In addition, a set of baseline data is presented. The performance in the treatment of 126 multiple injured patients was prospectively recorded from 1988 to 1993 and compared with an idealized process based upon an algorithm. The quality of present data recording was analysed, and criteria for judgement of quality of care were assessed. The algorithm was divided into 117 possible steps (one step consisting of a single decision criterion, the decision and the corresponding procedure). Per patient, only 61% +/- 12% of these steps were sufficiently documented to allow judgement. Using several criteria for assessment, the following baseline data could be observed (times shown refer to admission to the trauma room): (1) trauma room time of 129 +/- 55 min; (2) completion of basic radiological and sonographic diagnostics in 91% of patients; (3) first blood collection after 17 +/- 11 min; (4) cranial computerised tomography after 55 +/- 20 min; (5) missed injuries during the trauma room period in 32% of patients; (6) intubation after 20 +/- 19 min; (7) insertion of a chest tube after 30 +/- 17 min; (8) first blood transfusion in shock after 32 +/- 17 min; (9) transfused blood within the first hour of 4.2 +/- 2.8 units and within the second hour of 8.5 +/- 4.7 units; (10) emergency operations in shock after 98 +/- 55 min; (11) early operations after 156 +/- 69 min; (12) craniotomy after 124 +/- 37 min; (13) unplanned surgery within 24 hours after admission to the intensive care unit in 11% of patients. The study presented here supplies information on timing and other process data of the acute clinical care of seriously injured patients. In particular, the data represent indicators for the quality of emergency room management, which may be used as baseline to compose improvement measures of structure and process. The quality of data collection has to be improved for carrying out an exact analysis of the process.

Pediatric trauma care with computed tomography—criteria for CT scanning

“…Like other authors, we observed missed diagnoses in early trauma care ending with discharge from hospital [10,12,13,16,17,21,23,27,31,37]. After the ER phase with CT diagnostics and immediate data evaluation, only 3 single diagnoses (2.1 %) in 2 children (2.8 %) were missed.…”

Delays in diagnosis in early trauma care: evaluation of diagnostic efficiency and circumstances of delay

“…Most of these did not require any specific therapy. Like many other authors, we concentrated on missed diagnoses in early trauma care ending with discharge from hospital [14][15][16][17][18][19][20][21]23]. This is why missed injuries were called ''delays in diagnosis:'' they were detected during hospitalization.…”

“…Enderson et al [18] reported 41 missed injuries in 26 of 399 patients (9%). Zintl et al [23] reported 44 missed diagnoses in 32% of the patients after the ER phase. They judged five missed diagnoses as unjustified and potentially life-threatening.…”

“…Unjustified delays in diagnosis have led to delays in surgery and are caused by misinterpretations of initial radiographic or diagnostic procedures with significant morbidity [15,16]. Most delays in diagnosis are justified and acceptable, with some being unjustified, unacceptable and potentially life-threatening [14][15][16]23].…”

Epidemiological and economic aspects of polytrauma management in Austria

“…Quality management of the severely injured became the main argument to support centralization [6,7]. Another strong argument is the economic dimension.…”