Trauma quality improvement program

The Trauma Quality Improvement Program (TQIP) was initiated in 2008 by the American College of Surgeons Committee on Trauma. Its aim is to provide risk-adjusted data for the purpose of reducing variability in adult trauma outcomes and offering best practice guidelines to improve trauma care. TQIP makes use of national data to allows hospitals to objectively evaluate their trauma centers' performance relative to other hospitals. TQIP's administrative costs are less than those of other programs, making it an accessible tool for assessing performance and enhancing quality of trauma care. The Trauma Quality Improvement Program (TQIP) was initiated in 2008 by the American College of Surgeons Committee on Trauma. Its aim is to provide risk-adjusted data for the purpose of reducing variability in adult trauma outcomes and offering best practice guidelines to improve trauma care. TQIP makes use of national data to allows hospitals to objectively evaluate their trauma centers' performance relative to other hospitals. TQIP's administrative costs are less than those of other programs, making it an accessible tool for assessing performance and enhancing quality of trauma care. Morbidity and mortality rates are variable across United States trauma centers. Institutional variations can be attributed to differences in both patient population and quality of care at each institution. The Institute of Medicine (IOM) report To Err is Human: Building A Safer Health System emphasized the importance of recognizing variability and inefficiencies in the United States healthcare system. To address these discrepancies, John Fildes, MD, FACS created an ad hoc work group to create and implement an outcomes-based, validated, risk-adjusted trauma quality improvement system. The goal was to utilize existing trauma infrastructures to measure and continually improve the quality of trauma care. This was done by accessing each hospital's registry database using the National Trauma Data Standard (NTDS) from the National Trauma Data Bank (NTDB), resulting in the creation of the Trauma Quality Improvement Program (TQIP) by the American College of Surgeons (ACS). TQIP was preceded by surgical indicators that included the Optimal Resources for the Care of the Injured reference document, published by the ACS Committee on Trauma in 1979. The document created a framework for the trauma center verification review process with a systems approach to trauma care. The Major Trauma Outcome Study (MTOS) of 1982–1989 subsequently established the national standards for trauma care. The MTOS database also facilitated the creation of a methodology to estimate an individual trauma patient's survival probability, also known as the Trauma Injury Severity Score (TRISS). Other studies, such as the 2006 National Study of the Costs and Outcomes of Trauma (NSCOT), aimed to identify differences in expenditures and outcomes at various hospitals. A pilot study was initiated in June 2008 to refine the methodology and assess the feasibility of applying TQIP for quality improvement at different trauma centers. Twenty-three Level I and II trauma centers volunteered and were selected to participate in the study with ACS verification. Most Level I centers are university-based trauma centers with comprehensive services. Level II centers were included to increase geographic and patient diversity, as well as the statistical power of any analyses. Each participating center received a registrar training course that included information about TQIP objectives and infrastructures, critical data collection fields, and NTDS data definitions. Webinars with conference calls and test case data abstraction were used for follow-up training. Using NTDB data from patients admitted to trauma centers between January 1 and December 1, 2007, three cohorts were created. The first cohort included patients with blunt multisystem or blunt mechanism traumas with an Abbreviated Injury Scale (AIS) score ≥ 3 in two or more regions including the head, face, neck, thorax, abdomen, spine, and extremities. The second cohort was composed of trauma patients with penetrating truncal injuries with an AIS score ≥ 3 in at least one region including the neck, thorax, and abdomen. Patients in the third cohort had a blunt single-system injury with an AIS score ≥ 3 in only one AIS body region, with the remaining regions having a maximum AIS score of 2. The outcomes of interest were death during hospitalization as evidenced by an emergency department (ED) discharge disposition of “death” or hospital discharge disposition of “expired,” as well as the prevalence of inpatient complications. Data reports were created and distributed to each participating trauma center in June 2009. Results were consistent with the previous year's baseline findings. Cohorts of similar verified trauma centers had differences in risk-adjusted mortality rates with a large amount of variance between low-outlier and high-outlier trauma centers. The aggregate group had a relative risk-mortality of 3.3, while the single-system trauma cohort had a mortality 5.9 times higher for high-outlier facilities. The TQIP pilot results gave each trauma center feedback regarding their trauma outcomes relative to other hospitals. The results also shed light on appropriate actions to undertake in order to improve quality, such as by illuminating local or regional collaborative efforts that could implemented. Overall, the pilot study demonstrated that TQIP's anonymous measures of relative performance could successfully allow trauma centers to identify shortcomings and facilitate quality improvement using existing resources and systems at local, regional, and national levels. TQIP utilizes a retrospective cohort of trauma patients in designated and ACS-verified Level I and II hospitals in the United States and Canada. There is no minimum sample size requirement for a trauma center to participate in the program. As of 2014, over 200 participating Level I and II trauma centers that vary in type (public, private teaching university, teaching community, etc.) and region participate in TQIP. To participate in the program, patients must meet the following inclusion criteria: be an adult greater than sixteen years of age with at least one valid ICD 9 CM diagnosis code, history of blunt or penetrating mechanisms of injury, or have an AIS score ≥ 3. Eligible patients also must have emergency department or hospital dispositions available.