4. PI: PI Tracking
• PI Tracking
• Tracking tool available in Web Registry
• Includes all PI steps identified by ACS
• All trauma information stored in one secure location
7. PI: PI Tracking
• Activate PI Tracking
• Quick Review
• High-lite PI filter to be tracked on “Filter” screen
• Select Edit
• Check activate tracking box “yes”
• Close edit box with “ok”
• Go to PI Tracking screen
• Select Auto-trigger filter
• Moves all filters identified for tracking to the PI tracking screen
8.
9.
10. PI: PI Tracking
• PI Tracking
• Includes all PI steps identified by ACS
• Issue Identification
• Levels of Review
• Conclusions/evaluation
• Action Plan
• Implementation
• Evaluation / “Loop Closure”
11. PI: PI Tracking
• QA Item
• Auto assigned to the filter by ESO (DI)
• Be careful you can change the number & change filter
• Displays text of filter
• Check – make sure you have the right filter
12. PI: PI Tracking
• Date Opened
• Date the PI filter was identified for review
• Date filter identified Important for timeliness of PI review
• Common complaint - delay of PI case reviews
• Time Goal for PI review1:
• 30-60 days – case with care appropriate
• 60-80 days - case which raise questions
13. PI: PI Tracking
• Location
• Location where the PI filter occurred
• Unable to determine location use “Unknown”
• Don’t assign location randomly
• A report by location will be inaccurate
14. PI: PI Tracking
• If Prehospital
• EMS agency transporting patient IF EMS filter
• Not EMS filter, leave blank
15. PI: PI Tracking
• Service
• Specialty of physician identified to be responsible for the PI
issue, or
• Attending physician at time of PI issue
• Unable to determine physician responsible for PI filter
• Enter the attending physician
16. PI: PI Tracking
• Reviewed by
• Each level of PI review
• List each and every level of review on a separate line
• Can list up to 8 levels of reviewers
17.
18.
19.
20. PI: PI Tracking
• Result
• Result of final “Reviewed By” reviewer
• Highest level of review
• Trauma Registry staff will enter result – determined from review result
• Practitioner (or committee) performing the highest level of review will select
result
• Physician care evaluation & result determined by like-physician (peer)
• System issues (facility-wide) result determine by Multidisciplinary Trauma
Committee
21. PI: PI Tracking
• Result
• Definitions should be consistent with the facility’s PIPS
• Allows for integration with the facility-wide PIPS process
• Benchmarking – results mean the same
• PIPS aware of how trauma care is being evaluating (share your program)
• Reviews Results
• Appropriateness and timeliness of care
• Opportunities for improvement
• Errors in judgment, technique, treatment, or communication
• Delays in assessment, diagnosis, technique, or treatment
22. PI: PI Tracking
• Result Options
• Delay in Consult
• Delay in Diagnosis
• Delay in Intervention
• Delay in Medical Response
• Delay in Presentation
• Error Diagnosis
• Error Judgment
• Error in Management
• Error Technique
• Standard of Care Met
• Unavoidable Complication
23. PI: PI Tracking
• Result Options
• Delay in Consult
• Delay requesting consult
• Delay in Diagnosis
• Delayed diagnosis occurs when the correct diagnosis is given but with a significant delay
that adversely affects the patient
• Signs and symptoms present but not diagnosed in timely manner
• Common problem, and often occur when one fails to timely order tests such as lab work, x-
rays, cat scans.
• Expect traumatic injury to all be diagnosed within 24 hours after presentation; but if
adversely affects patient delayed dx
24. PI: PI Tracking
• Result Options
• Delay in Intervention
• Life-saving surgery postponed
• Delay in Medical Response
• OR crew didn’t respond to Trauma Activation
• Lab delayed drawing timed H&H
• Trauma Team Activation delayed
• Medical doesn’t just mean physician – any medical response
• Delay in Presentation
• Delay in requested consults arrival
• Radiologist did not respond STAT, to read cat scans
25. PI: PI Tracking
• Result Options
• Error Diagnosis
• Error in Diagnosis same as misdiagnosis
• Misdiagnosis occurs when a practitioner diagnoses the patient with the wrong illness/injury
• C-spine fx diagnosed but has torn aortic arch
• Chest muscle strain diagnosed but has pneumothorax
• Error Judgment
• Issue with clinical judgment or decision
• Needed consult not requested/obtained
• Treated injury non-operatively when standard of care is to treat operatively
• Trauma Team NOT activated per protocol; ED staff wrongly downgraded trauma team activation level
upon hearing EMS radio report
• Physicians are permitted a broad range of judgment in their professional duties
• Reason for peer review
26. PI: PI Tracking
• Result Options
• Standard of Care Met
• No issue with provider care
• Standard of care followed
• Unavoidable Complication
• Is a known complication for a specific injury or intervention
• Even with the best care (standard of care met) the complication occurred
• Hypothermia due massive transfusion protocol even with all warming techniques instituted
• Surgical wounds may split open after surgery, even when the surgeon sewed the wound up correctly. If
wounds aren't healing well, or because of problems like severe coughing or vomiting.
• During complicated surgery, there’s a chance that a part of the patient’s body will be accidentally cut.
Sometimes, it may be unavoidable.
• When patients stay bedrest they're more likely to develop a serious blood clot in the veins of the legs, thighs,
or pelvis even with appropriate anticoagulation therapy
27.
28. PI: PI Tracking
• Comments
• Free-text field for comments on the PI issue.
• Enter where the case was referred
• Referred to Trauma Medical Director
• Referred to Outside Peer Review
• Enter reasons for delay
• Awaiting autopsy results
• Medical Director interviewing staff involved
• Literature search being conducted
• Delayed until next TC meeting
• Provides snap-shot summary of PI process
29.
30.
31. PI: PI Tracking
• Contributing Factors
• Any behavior, omission, or deficiency
• sets the stage for issue
• or increases the severity
• PI Tracking contributing factors options
• None Identified
• Communication Issue
• Deviation from Protocol
• Disease Related/Co-morbidity
• Equipment Issue
• Patient Behavior/Refusal
• Other
34. PI: PI Tracking
• System Related [Yes, No, NA, Unk]
• An event or complication not related to a provider or disease
• Operating room availability
• Blood availability
• Diagnostic test availability
• System-related issues usually involve multiple individuals and/or
departments
• Corrective action usually goes beyond a single provider or department
35. PI: PI Tracking
• System-Related = Yes
• Preventability
• Level of preventability of system-related issue
• Assigned by the highest level of reviewer(s)
• Preventability Options
• Unanticipated Event with Opportunity for Improvement
• Anticipated Event with Opportunity for Improvement
• Event without Opportunity for Improvement
• Undetermined Opportunity for Improvement
36. PI: PI Tracking
• Disease Related [Yes, No, NA, Unk]
• An issue or complication that is an expected sequela of a disease, an illness, a treatment, or
an injury
• Examples:
• UTI after prolonged but necessary urinary catheter
• ARDS from injury despite best available treatment
• Renal failure despite preventative measures
• Intra-abdominal abscess following damage control laparotomy despite good surgical technique and
appropriate antibiotics
• Atrial fibrillation after appropriate fluid resuscitation
• Skin sloughing over area of contusion in elderly patient
• Intracranial hemorrhage during appropriate therapy
• Stress ulcer despite appropriate prophylaxis
37. PI: PI Tracking
• Disease Related = Yes
• Grade
• Grade of severity of disease-related issue
• Assigned by the highest level of reviewers
• Grade Options
• Grade Not Assigned
• Grade I – Non-life Threatening (No Lasting Disability)
• Grade II – Potentially Life Threatening (No Residual Disability)
• Grade III – Life Threatening (Residual Disability)
• Grade IV – Death
38. PI: PI Tracking
• Provider/Team Related [Yes, No, NA, Unk]
• An event or complication largely due to provider-related provision of
care in a well-functioning system
• By a credentialed provider
• By non-credentialed provider
39. PI: PI Tracking
• Provider/Team Related = Yes
• Acceptability
• Acceptability of provider-related issue
• Assigned by highest level of reviewer
• Acceptability Options
• Acceptable
• Acceptable with Reservations
• Unacceptable
40.
41. PI: PI Tracking
• Corrective Action
• Actions designed to prevent reoccurrence of the PI issue or complication
• May need more than one correction action
• Structured effort to improve suboptimal performance
42. PI: PI Tracking
• Corrective Action options
• System Related Issues
• Formulation of New Policy/Procedure
• Change in Policy or Procedure
• Education Offered
• Equipment Obtained/Repaired
• Letter to Department Head
• Letter to Physician/Institution
• Findings from Other Committees Presented to M&M
• Institution of Formal QA Audit
• Tabulation & Tracking of Problem for Further Reporting
• Not Documented
• Other – Describe in Comments
• Action Pending Review
• No Action Required
43. PI: PI Tracking
• Status
• Status of corrective action.
• Status Options
• Pending
• Active
• Closed
44. PI: PI Tracking
• Loop Closed
• Date the PI issue closed.
• Date – PI issue review completed and standard of care met
• No corrective action needed
• If corrective action needed:
• Closure of loop implies that the process or outcome has been:
• Measured after implementation of corrective action plan
• And improvement has been demonstration.
• The word “loop” refers to a cycle of:
• Monitoring
• Finding
• Fixing
• Monitoring again
45. PI: PI Tracking
• Loop Closed
• The ATR with attention to PI is “monitoring”
• Loop closure means:
• Has corrective action made a difference?
• Is follow up or continued monitoring needed?
• Can the loop be closed or not?
• Loop Placement on QA Tracking screen is out of sequence
• Last field to be completed on this screen
46.
47. PI: How to Use Report Runner
• Run All report Runner Reports Timely
• Monthly or Quarterly
• Run PI Tracking Report
• Use this as individual case review
• Can see any commonalities, system issues arise?
• As mentioned – Registry or TPM review might be all that is needed
• Document this!
48. PI: How to Use Report Runner
• Standard Reports
• Standard - ACS Filters
• Standard - ACS List
• Standard – Alaska State Defined Filters
• Over/Under Triage Analysis – Monthly/Quarterly
• Over/Under Triage Patient Summary – Monthly/Quarterly
• PI Tracking – Can use prepopulated or as template
50. PI: How to Use Report Runner – ACS Filters
ACS manually answered
filters will be on available
for tracking on PI
Tracking.
ACS logic generated
filters will not be on PI
Tracking.
Can add through System
Filters-Complications if
one is available or you
may manually add to the
PI Tracking report (thru
Excel).
52. PI: How to Use Report Runner – Alaska Defined Filters
AK Defined Filters will be
available for tracking on
PI Tracking screens.
53. PI: How to Use Report Runner - Over/Under Triage
Over/Under Triage can be
added by adding thru
Complications-System
Filters under EMS
Miscellaneous – Other
Prehospital.
54. PI: How to Use Report Runner – Over/Under Triage
55. PI: How to Use Report Runner
PIIssue
Howwasthe
issue
Identified
Patient
Name(s)
Trauma
Number(s)
Medical
Record
Number(s)
QA
Code(s)
Open
Date
LoopClosed
Date
Locatio
n(s)
If
Prehos
pital Service
Review
Date1
Reviewed
By1
Review
Result1
Review
Comment1
Contributing
Factor1
Contributing
Factor2
System
Related Preventability
Disease
Related Grade
Provider
Related
Accepta
bility
Corrective
Action1
Corrective
Action1
Status
Corrective
Action2
Corrective
Action2
Status
Monitoring
ATR
Abstacting
EMSrunreports
ATR
Abstacting
MTPProtocol
ATR
Abstacting
Receiving
informationfor
ATR
Abstacting
NotDocumenting
GCS
ATR
Abstacting
58. PI: PI Documentation
• Short and to the point on PI Form
• PI Issue
• Level of Review
• Level 1 – effectively dealt with by Trauma Coordinator/Program Manager
• Level 2 – effectively dealt with by Trauma Director and Trauma Coordinator
• Level 3 – effectively dealt with by one of various
• Conclusion
• Briefly state what was discussed and decided
• Action plan
• What is going to be done to improve the performance of trauma care.
• Implementation
• What, where, and when the action plan was put into place
• Continue to monitor for a period of time to be sure plan was effective
• Closed
• “Closed the loop”
60. PI: PI Tracking
• Just a Few Tips
• The sooner the review, the better
• Be thorough and systematic
• Timely accurate collection & analysis of meaningful data is a challenge
• Trauma director must lead
• Must be multidisciplinary effort
• Figure out a system that works for you
• Keep an open mind, don’t pre-judge a case
• Start by presuming the system failed, not a person
• Should rarely be a punitive process
• It’s all about the next one
61. PI: PI Tracking
• Monitoring the performance of trauma care can identify
areas for:
• Improvement in patient outcomes
• More effective use of resources
• Methods to expedite appropriate care
• Areas of education/outreach/ injury prevention to focus on
• Protocol/guideline development
62. PI: Trauma Facility Designation
• Requirement for Alaska Trauma Designation
• Ongoing active PI program
• Not just a paper exercise
• Provides a forum for review that leads to improved
patient care
• Patient specific PI documentation
• Retained & readily available during the onsite
designation survey
63. PI: PI Tracking
• GOALS
• Reduce inappropriate variation in care
• Improve patient safety
