Section 325.135. Performance improvement.

(1) Each regional trauma advisory committee shall use the trauma registry data collected to improve trauma care through the appointment of regional professional standards review organizations, reduce death and disability, and correct local and regional injury problems.

(2)   Each regional trauma network shall appoint a professional standards review organization.

(3)      Deviations from recommendations and protocols, which are established and adopted by local medical control and approved by the department for trauma patients, shall be addressed through a documented trauma performance improvement process established by  a   professional  standards   review organization.

(4)   Data confidentiality. Each regional trauma advisory  committee   shall observe the confidentiality provisions of the health insurance portability and accountability act under 45 CFR Part 164, data confidentiality provisions under the code, or as established by the  regional  professional  standards review organization.

(5)       Process. The performance improvement process shall include the following standards that are incorporated by reference in these  rules,  pursuant  to  R 325.129(2)(l), and  include  all  of  the following for both pediatrics and adults:

(a)  ) Data collection and analysis.

(b)    Adult and pediatric-specific quality indicators for evaluating the trauma system and its components.

(c)   ) A system for case referral.

(d)  A process for indicator review and audit.

(e)   ) A mechanism for an action plan and process improvement.

(f)  A mechanism for feedback to the medical control authorities, the emergency medical services coordinating committee, and  the   state  trauma  advisory subcommittee.

(g)   An evaluation of system performance to include all of the following:

(i)   Designation: Compliance with criteria.

(ii)   Triage and transport (Access).

(iii)   Outcomes: (stratified by ISS/TRISS).

(iv)   Both of the following transfers:

(a)   LOS.

(b)   Deaths.

(v)   Both of the following patient care issues:

(a)   ) Mortality: all deaths.

(b)   Morbidity: Defined by regions.

(vi)   Review of hospital performance improvement.

(vii)   The following audit filters and data elements:

(A)   Trauma related deaths list hospital, elapsed time, ED admission time, MOI, age, cause code, transport mode, GCS, RTS, AIS, ICD-9, CPT's and ISS for each patient.

(B)   Trauma patients with more than one inter-hospital transfer prior to definitive care list hospitals sending and accepting the transfer for each patient meeting criterion.

(C)  Ground transport trauma patients with an ED RTS less than or equal to 5.5 and scene transport times (scene departure to ED arrival) greater than 20 minutes list (and sort by) hospital, transport mode, EMS agency, scene to hospital transport time, injury county, cause code, ISS, and outcome for each  patient meeting these criteria.

(D)   Trauma patients with EMS scene times (EMS scene arrival to EMS scene departure) greater than 20 minutes list EMS agency, transport mode, scene time, scene procedures (air, CPR, fluids), trauma type, injury zip code (injury county), ISS, and outcome for patients meeting criterion.

(E)   Transferred trauma patients with an ISS greater than 15 and transfer time (ED admit to definitive hospital admit) greater than 6 hours for rural place of injury or 4 hours for urban place of injury list ED hospital, definitive hospital, urban or rural place of injury, transfer time, cause code, ISS, and outcome for patients meeting criteria.

(F)    Trauma patients with an ISS greater than 15 and ED time (ED admit to ED discharge) greater than 2 hours list hospital, patient transfer? (yes or no), cause code, and ED time for patients meeting criteria.

(G)  Trauma patients who die with a probability of survival (TRISS) > 50%.(TRISS score for trauma patients using physiologic measures collected at the first presenting hospital) list hospital, age, cause code, transport mode, ISS, outcome, LOS, and TRISS for patients meeting criteria.

(H)   Trauma patients with an ISS greater than 15 who are discharged from non- trauma centers list hospital, age, cause code, transport mode, ISS, outcome, discharge disposition, and time to discharge for each patient meeting criteria.

(I)  Trauma patients transported by EMS without  an  associated   ambulance report in the medical record list percentage of missing run reports by transport mode and EMS agency.

(J)    Trauma patients 14 years of age or younger (children) who either had an ED GCS less than or equal to 8, intubation, or ISS greater than 15 and not transferred to a regional pediatric trauma center list hospital, age, ED GCS, ISS, cause code, LOS, and transport mode for each patient meeting criteria.

(5)  Trauma System Evaluation. Each trauma care region shall be responsible for the ongoing evaluation of its trauma care system.  Accordingly,  each region  shall develop a procedure for  receiving   information  from  EMS providers,  trauma  centers and the  local  medical  community   on  the implementation of various components of that region's trauma system, shall include the standards that are incorporated by reference pursuant  to  R 325.129(2)(l), as well as include all of the following;

(a)  The following system components to be evaluated:

(i)   Components of the regional trauma plan.

(ii)   Ttriage criteria, and effectiveness.

(iii)   Activation of trauma team.

(iv)   Notification of specialists.

(v)   Trauma center diversion.

(b)   Results to be reported annually. Based upon information received by the region in the evaluation process, the region shall annually prepare a report containing results of the evaluation and a performance improvement plan. Such report shall be made available to all EMS providers, trauma centers and the local medical community. The region shall ensure that all trauma centers participate in this annual evaluation process,  and encourage all other hospitals that treat trauma patients to do likewise. Specific information related to an individual patient or practitioner shall not be released.Aggregate system performance information and evaluation will be available for review.

(6)   Performance improvement process for trauma centers. All trauma centers shall develop and have in place a performance improvement process focusing on structure, process, and outcome evaluations which focus  on   improvement efforts to identify root causes of problems, intervene to reduce or eliminate

these causes, and take steps to correct the process as set forth in the trauma center level specific requirements. This system shall provide for input and feedback from these patients and guardians to  hospital  staff regarding the care provided. In addition, the process shall include the standards that are incorporated by reference pursuant to R 325.129(2)(l), and all of the following:

(a)  ) A detailed audit of all trauma-related deaths, major complications  and transfers.

(b)   A multidisciplinary trauma peer review committee  that   includes  all members of the trauma team.

(c)   ) Participation in the trauma system data management system.

(d)     The ability to follow up on corrective actions to ensure performance improvement activities.

(7)   Performance improvement process for trauma care regions. Each trauma care region shall be required to develop and implement a region wide trauma performance improvement program. This program shall include the  standards that are incorporated by reference pursuant to R 325.129(2)(l), and shall include the development of an annual processes for reporting to the department a review of all region-wide policies, procedures, and protocols.

History: 2007 AACS.