Audit Filters Research Articles

The evaluation of pediatric trauma care using audit filters

To evaluate the experience of a pediatric trauma system with specific reference to prehospital, trauma center resuscitation, and critical care phases of treatment. Descriptive review of concurrent audit. A tertiary care referral adult and pediatric trauma center. All pediatric trauma victims in the trauma registry (includes patients < or = 14 years old, who died or were hospitalized for > or = 24 hours). None. Age, pediatric trauma, injury severity, and Glasgow Coma Scale scores as well as outcome (death or discharge disability score) were analyzed. Primary filters (those with the potential to contribute to morbidity and mortality), secondary filters (minor deviations from care), missed injuries and all deaths were reviewed. Of 250 patients in the registry, 20 died. One hundred thirteen had filters, with 49 having primary filters (34 with one, 14 with two, and one with four filters). Fifty percent of primary filters occurred in the prehospital phase of care with inadequate airway management and venous access accounting for 60%. Overall, primary filters occurred more commonly in patients with severe injuries (lower Pediatric Trauma and Glasgow Coma Scale and higher Injury Severity scores). Primary filters were also statistically more common in patients who died or who were disabled. In three patients (25%) who died, our review suggested that filters may have contributed to demise. Missed injuries were mostly extremity fractures and did not contribute to mortality or long-term morbidity. Deviations from care occur, even in a dedicated pediatric trauma system. Mortality of and by itself is not an adequate indicator of the quality of function of a trauma system. Since most primary filters occurred outside of the trauma center, improvement in trauma outcome may be expected with better training of personnel involved in the prehospital care of injured children. A comprehensive review of death and disability should include audit filters of prehospital care, triage, definitive care, and rehabilitation.

American College of Surgeons audit filters: associations with patient outcome and resource utilization.

To determine if trauma patients qualifying by a 1990 American College of Surgeons (ACS) audit filter have the same outcomes and resource utilizations as similar (matching) patients not qualifying by the filter. Retrospective, case control study. Data for 21,175 patients submitted during 1992 to the Pennsylvania Trauma Outcome Study (PTOS) were analyzed. Patients qualifying by each 1990 ACS audit filter were identified, except filters 13 and 22 that were not accommodated by the PTOS form. In addition, qualifiers by filter 21 (trauma deaths) were not analyzed. For each qualifier by a filter, matching patients who were not qualifiers by the filter were identified. Matching patients had the same cause of injury, A Severity Characterization of Trauma (ASCOT) age category, distribution of serious (Abbreviated Injury Score of > 2) injuries, intubation status, and coded Revised Trauma Score values on Emergency Department arrival. Qualifiers and matching patients were compared for their survival (z and W statistics), discharge disability (PTOS-Functional Independence Measure), and lengths of stay in the hospital (H-LOS) and in the Intensive Care Unit (ICU-LOS). More than 57% of the study sample qualified by one or more filters. Filters 10 and 12 did not have sufficient qualifiers for evaluation. No filter's qualifiers were associated with significantly more disability at discharge than matching patients. The most frequently occurring filters (4, 2, and 5, respec-tively) deal with documentation deficiencies, but were not associated with significant results. Qualifiers by the nine filters below were associated with significantly greater mortality or H-LOS or ICU-LOS. [table: see text] Additional studies of the efficacy and efficiency of trauma quality assurance filters are needed. Objective criteria should be established for the definition, evaluation, modification, and adoption of trauma audit filters.

American College of Surgeons trauma quality indicators: an analysis of outcome in a statewide trauma registry.

Quality assurance/quality improvement (QA-QI) is a priority for maintaining the highest standards of care in trauma systems. To be an effective tool for system review, the QA-QI indicators should identify patients with higher rates of morbidity and mortality from injury. While the American College of Surgeons (ACS) and the Joint Commission on Accreditation of Health Care Operations have identified certain audit filters within the trauma system, there are few data to substantiate the value of these audit filters for trauma care. The purpose of this study was to analyze the ability of the ACS trauma indicators to predict adverse patient outcome following injury requiring review. The study population consisted of 44,019 patients from the North Carolina State Trauma Registry from 1987 to 1992. Of the 22 audit filters nine were available for analysis. Mortality rate, length of stay, and total charges were used as measures of outcome. The hypotheses tested were that patients who met the indicator criteria would have higher mortality rates and worse outcomes than the non-indicator group. Student's t test and Chi-square analysis were used to test the differences between the group which met the criteria for the indicator and those without. Of the nine audit filters tested, only three were found to have significantly worse outcomes than their non-indicator comparison group: gunshot wound to the abdomen with non-surgical management, femur fracture without fixation, and complications from pulmonary embolism-deep vein thrombosis-decubitus ulcer (p < 0.05). Contrary to expectations, four of the audit filters, coma without intubation, laparotomy > 2 hours, transfer > 6 hours, and admission to non-surgical service, actually had significantly better outcomes than their non-indicator counterpart. Scene time > 20 minutes, laparotomy > 2 hours after arrival, and craniotomy > 4 hours after arrival may be indicators of patients at risk for morbidity. This study demonstrates that several ACS clinical indicators, as currently written, are not useful in identifying patients at higher risk for poor outcome. The indicators need further definition to be of value in the quality review process. Specifically, the study suggests that audit filters should be data driven and based upon analyses of large populations of injured patients and their outcomes to be valid QA-QI tools.

PEDIATRIC TRAUMA PATIENTS IN AN ‘ADULT' TRAUMA CENTER

The injury patterns, age distribution, and outcome of pediatric patients (age < 15 years) treated in an "adult" trauma center is incompletely defined. A total of 1115 pediatric trauma patients (9.6% total trauma admissions) treated over a 6-year period in a level I suburban trauma center without a pediatric trauma service or a pediatric surgeon were reviewed for age distribution; injury mechanism, injury pattern, and injury severity; surgical procedures; disposition; and mortality. All charts were subject to internal and external peer review, including five site surveys. Resuscitation, surgery, critical care, and stepdown management were provided by a trauma team led by in-house attending trauma surgeons (mean PGY = 20). Of the patients 22% were preschool (age 0-4 years), and 34% were adolescent (age 12-14 years); the mechanism was blunt (96%), with motor vehicular crash being the most frequent; the mean ISS was 11.1, with 39% of ISSs > 9; significant injuries (AIS score > or = 3) of the head and extremities were dominant; 3.9% of patients underwent laparotomy, primarily for injuries to the bowel, spleen, and liver. There was only one laparotomy in the 0-4 year age group. The mean length of stay of patients was 6.2 days, with 38% requiring time in the ICU. Of the patients, 90% were discharged home; the treated trauma patient mortality rate was 25 of 988, or 2.5%; 92% of these died of nonsurvivable head injuries. No deaths were judged preventable. There was no significant difference of noncompliance for the pediatric patients when compared with the adult population in five trauma audit filters.(ABSTRACT TRUNCATED AT 250 WORDS)

Audit filters in quality assurance in pediatric trauma care

Quality assurance (QA) systems use audit filters to help identify not only deaths and medical complications, but also cases that reflect deficiencies in the timeliness or appropriateness of care. Through our trauma center QA process, we studied three groups of audit screens for trauma care: two set forth by the Committee on Trauma of the American College of Surgeons, a minimum set of 12 audit filters proposed in 1987 and an expanded version recently proposed in 1990 (studied retrospectively), and one set of filters already in use in our system. A peer review committee determined whether deaths and complication were preventable, and judged the timeliness and appropriateness of care. From July 1, 1989, through June 30, 1990, 844 admitted trauma patients came under QA review. During this period 13 (1.5%) died; 35 (4.1%) suffered at least one medical complication. 140 children (16.6%) violated one of the 12 minimum audit filters suggested by the Committee on Trauma (which includes deaths and medical complications), one of the additional filters used by the Trauma Program QA system, or both. Ninety patients (10.6%) failed one of the 12 minimum audit filters; 104 (12.3%) failed one of the additional filters used by the Trauma Program QA system. Filters that involved medical management issues (late operations, return to operating room, airway, failed reduction, infections, missed injuries, readmissions to intensive care unit, return to the emergency department) frequently involved aspects of inappropriate care (72.5%, 37/51 violations) and were associated with actual deaths or medical complications (52.9%, 27/51).(ABSTRACT TRUNCATED AT 250 WORDS)

Quality Assurance for Patients with Head Injuries Admitted to a Regional Trauma Unit

The efficacy of trauma systems in reducing preventable deaths has been established but the methods of auditing care are still evolving. Various "audit filters" to identify which patients' charts should be reviewed have been proposed. An analysis of all patients admitted to the Regional Trauma Unit (RTU) over a 19-month period was conducted. Of 729 patients, 135 were identified as having suffered a traumatic intracranial hemorrhage (TICH). On review, neither delay in transfer from the emergency room to the operating room nor increasing time from the incident to the operating room correlated with increasing mortality. In contrast to delay, the Glasgow Coma Scale (GCS) score on admission correlated well with outcome. The charts of patients with anomalous outcomes based on admission GCS score were reviewed, and two possibly preventable deaths were identified. There were 48 patients with TICH who had no operations but there were no deaths attributable to a missed operation. There were 76 patients for whom the GCS score at the referring hospital and the GCS score on admission to the RTU were available. Seven of 19 patients who worsened on transfer declined because of significant pulmonary injuries. Anomalous outcomes based on admission GCS score and declining GCS scores are recommended as quality assurance filters.

Cost Effectiveness of Trauma Quality Assurance Audit Filters

The American College of Surgeons Committee on Trauma (ACSCOT) has published recommended minimal audit filters for trauma quality assurance. In this study ten filters were assessed through variable sample sizes over a 1-year period for cost and efficiency. Each filtered case was screened by trauma nurse coordinators. The trauma director reviewed possible deviations from standard and presented cases at peer review conferences for consensus on problem identification. While several filters had reasonable yield, most filters had minimal or no yield. Ten de novo problems were identified at a cost of +1,000 per de novo problem. Six filters were modified based on common reasons for overfiltration, resulting in a substantial reduction in filtration rate without losing problem identification. We conclude that ACSCOT audit filters 1 (unexpected deaths), 4 (ICU LOS greater than twice the average), 5 (trauma surgeon response), and 9 (major surgery greater than 24 hours) have a reasonable yield. Filters 2, 3, 7, 8, 11, and 12 have limited value to an established suburban trauma center and are not cost effective. Modifications of these filters can reduce cost without obvious impact on effectiveness. Specific audit filters recommended for future study are presented.