EMS Audit Filters              Monitored Purpose                   

      100% Traumatic Deaths                                                                                Care Appropriateness

        Air Medical Utilization                                                                             Utilization Appropriateness

                      *Meets Air Medical Triage Criteria

        Attempted Intubations             Care Appropriateness

                                                                                                                *RSI Monitored via RSI Audit Tool

  Triaged direct to Trauma Center                                                                       Triage Appropriateness                                              

© 2009 MTAC Metrolina Trauma Advisory Committee Copyright. All Rights Reserved / Web Design Mike Jordan, RN

Trauma Performance Improvement

Performance Improvement, “PI” is a term recommended by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to describe continuous evaluation of a trauma system and trauma providers through structured review of process of care as well as outcome (American College of Surgeons).

Trauma Performance Improvement can be described in its simplest form as a method by which the delivery of care and the system that supports its delivery remain continually monitored, evaluated and improved. This process ensures that the various elements of the trauma system are in fact, operating in an organized and coordinated fashion that improves overall outcome from traumatic injury. The MTAC prioritizes regional performance improvement through daily collaboration and dialogue with its member facilities and EMS agencies.  (See Regional PI form).

MTAC Performance Improvement measures are aimed at reducing the morbidity & mortality of injury and is accomplished through continuous development and monitoring of the following performance improvement strategies:

•Reduction in variations of care through standardization of processes

•Improvement in efficacy, access and timeliness to definitive care

•Ensuring competent & current providers

•Ensuring effective and appropriate utilization of trauma systems and associated resources

•Identifying consistent mechanisms for reporting issues (Regional PI form)

•Identifying areas of improvement and effective process management

The following describes a list of discretionary audit filters by which all MTAC regional facilities and EMS systems are encouraged to monitor internally:

   Community Hospital Autid Filters  Monitored Purpose

         100% Traumatic Deaths                                                                              Care Approptiateness

  ED Length of Stay (LOS) > 90 Minutes     Care Appropriateness

    * Delay in Transfer

      Non Trauma Center ICU Admission     Triage Appropriateness

          Blood Product Administration                                                                 Resuscitation Appropriateness

       * Meets ATLS Guidelines

Trauma Performance Improvement