Trauma Center Performance Improvement And Patient Safety Plan (Page 7 of 9) in pdf

Trauma Center Performance Improvement And Patient Safety Plan Page 7

APPENDIX B

The following are examples of indicators used to measure, evaluate, and improve

trauma center/system performance.

Process Measures

 Trauma patients with ISS >9 and ED Length of Stay > 2 hours for patients

transferred out

 Trauma Team activation for all patients with initial BP < 90

 Trauma Team activation criteria not followed

 EMS scene time > 20 minutes for all patients with an ISS >15 or all

penetrating trauma arriving from the scene

 EMS transport time >45 minutes

 Patients with GCS < 8 without definitive airway established by EMS

 Patients with GCS<8 without definitive airway established within 5 minutes of

ED arrival

 Chest tube not placed for pneumothorax or hemothorax within 15 minutes of

diagnosis

 Inability to obtain vascular access in a patient with unstable vital signs

 Denial of transfer by higher level of care facility

 Required equipment which is shared with other departments(i.e. fluid warmer)

not immediately available when requested)

Outcome Measures

 Trauma Death

 Functional Independence Measure Scoring(FIM)

 Trauma patients admitted that develop complications or require transfer to a

higher level of care(complication is defined as any untoward event causing

increased length of stay, resource utilization, morbidity, mortality)

Additional Optional Indicators:

 EMS run report not left at hospital by EMS personnel

 Infusion of more than 40ml/kg crystalloid within 2 hours in a pediatric patient

with normal vital signs

 Readmission or return to the ED within 72 hours

Created 01-12-2012

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Trauma Center Performance Improvement And Patient Safety Plan Page 7