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  • Measure Summary
  • NQMC:009698
  • Jan 2013

Adult trauma care: percentage of patients age 18 years and older admitted to hospital with an injury diagnosis who die.

Guide to quality indicators in adult trauma care. Version 3. Calgary (AB): Quality of Trauma in Adult Care, University of Calgary; 2013 Jan 29. 129 p. [111 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

Primary Measure Domain

Clinical Quality Measures: Outcome

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients age 18 years and older admitted to hospital with an injury diagnosis who die (per 100 patients).

Note: The developer proposes calculating two risk-adjusted mortality rates:

  1. One for deaths during initial hospital stay = in hospital mortality.
  2. One for deaths during the first 12 months following injury = mortality rate 12 months following injury.

Although data for in hospital mortality is easier to obtain than data for 12 month mortality, both measures provide potentially important and slightly different evaluations of patient care outcome.

Rationale

Each year, injuries affect 700 million people worldwide and result in more than five million deaths. In many countries, injuries are the leading cause of death among those under the age of 45 years. The human and societal burden is even greater with many survivors never returning to school, work or their "regular" lives.

Health care services provide patients with treatment for what is a major cause of morbidity and death. Yet medical errors and substandard care threaten trauma care. Half of all patients with major traumatic injuries do not receive recommended care, medical errors are common in critically ill trauma patients and preventable trauma deaths in hospital are widely reported. The World Health Organization (WHO), professional trauma organizations (e.g., American College of Surgeons [ACS], Trauma Association of Canada and Royal Australasian College of Surgeons) and accreditation bodies have promoted efforts to improve the quality of care delivered to injured patients. However, before the quality of injury care can be improved, it needs to be measured using reliable and valid measures of health care quality.

These indicators can be used to assess patient safety, and to evaluate and improve quality of care by incorporating these measures into local, regional or national quality improvement efforts. Implementing a consistent approach to measurement (same indicators, same definitions, same data elements, same reporting format) would provide institutions with reliable performance data that is necessary for surveillance (e.g., tertiary survey completion), to track local problems (e.g., adverse events – specifically missed injuries), evaluate the effects of interventions or program changes (e.g., tertiary survey protocol) and provide comparisons across centers (e.g., benchmarking adverse events using programs such as the ACS's Trauma Quality Improvement Program). Well-designed, carefully evaluated and appropriately implemented quality indicators (QIs) may be essential tools for guiding efforts to improve health and healthcare.

This indicator is intended to monitor risk-adjusted mortality in hospital and 12 months from injury and allow comparisons across institutions.

Evidence for Rationale

Guide to quality indicators in adult trauma care. Version 3. Calgary (AB): Quality of Trauma in Adult Care, University of Calgary; 2013 Jan 29. 129 p. [111 references]

Primary Health Components

Trauma care; injury; death

Denominator Description

All patients age 18 years and older admitted to hospital with an injury diagnosis (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

All patients age 18 years and older admitted to hospital with an injury diagnosis who die

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Most studies show no correlation between the indicator and individual measures of process, but some correlation with composite measures of process (Cryer et al., 1996). Two studies showed poor agreement between risk adjustment using Trauma Score – Injury Severity Score (TRISS) and A Severity Characterization of Trauma (ASCOT) (Glance et al., 2004; Glance, Osler, & Dick, 2005).

Evidence for Additional Information Supporting Need for the Measure

Cryer HG, Hiatt JR, Fleming AW, Gruen JP, Sterling J. Continuous use of standard process audit filters has limited value in an established trauma system. J Trauma. 1996 Sep;41(3):389-94; discussion 394-5. PubMed External Web Site Policy

Glance LG, Osler TM, Dick A, Mukamel D. The relation between trauma center outcome and volume in the National Trauma Databank. J Trauma. 2004 Mar;56(3):682-90. PubMed External Web Site Policy

Glance LG, Osler TM, Dick AW. Evaluating trauma center quality: does the choice of the severity-adjustment model make a difference?. J Trauma. 2005 Jun;58(6):1265-71. PubMed External Web Site Policy

Extent of Measure Testing

Using a modification of the RAND/University of California, Los Angeles (UCLA) Appropriateness Methodology, a panel of 19 injury and quality of care experts serially rated and revised quality indicators identified from a systematic review of the literature and international audit of trauma center quality improvement practices. The quality indicators developed by the panel were sent to 133 verified trauma centers in the United States, Canada, Australia, and New Zealand for evaluation.

A total of 84 quality indicators were rated and revised by the expert panel over 4 rounds of review producing 31 quality indicators of structure (n=5), process (n=21), and outcome (n=5), designed to assess the safety (n=8), effectiveness (n=17), efficiency (n=6), timeliness (n=16), equity (n=2), and patient-centeredness (n=1) of injury care spanning prehospital (n=8), hospital (n=19), and posthospital (n=2) care and secondary injury prevention (n=1). A total of 101 trauma centers (76% response rate) rated the indicators (1=strong disagreement, 9=strong agreement) as targeting important health improvements (median score 9, interquartile range [IQR] 8 to 9), easy to interpret (median score 8, IQR 8 to 9), easy to implement (median score 8, IQR 7 to 8), and globally good indicators (median score 8, IQR 8 to 9).

Thirty-one evidence-informed quality indicators of adult injury care were developed, shown to have content validity, and can be used as performance measures to guide injury care quality improvement practices.

Trauma centers rated the indicator "percentage of patients age 18 years and older admitted to hospital with an injury diagnosis who die" as targeting important health improvements (median score 9, IQR 8 to 9), easy to interpret (median score 9, IQR 8 to 9), easy to implement (median score 9, IQR 7 to 9), and globally a good indicator (median score 9, IQR 8 to 9).

Evidence for Extent of Measure Testing

Santana MJ, Stelfox HT, Trauma Quality Indicator Consensus Panel. Development and evaluation of evidence-informed quality indicators for adult injury care. Ann Surg. 2014 Jan;259(1):186-92. [35 references] PubMed External Web Site Policy

State of Use

Current routine use

Current Use

Accreditation

Internal quality improvement

Measurement Setting

Hospital Inpatient

Intensive Care Units

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Institutionalization

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All patients age 18 years and older admitted to hospital with an injury diagnosis

Exclusions
Indicator is restricted to patients admitted to hospital. Patients who die prior to hospital arrival or who die in the emergency department (ED) prior to being admitted to hospital are excluded.

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
All patients age 18 years and older admitted to hospital with an injury diagnosis who die

Exclusions
Unspecified

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Registry data

Type of Health State

Death

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Risk adjustment devised specifically for this measure/condition

Description of Allowance for Patient or Population Factors

Risk Adjustment: Age, sex, pre-existing conditions and a validated Injury Severity Score (ISS) (e.g., abbreviated ISS [AIS] or International Classification of Diseases-based ISS [ICISS])

How to calculate Risk-adjusted Mortality Rate:

Risk-adjusted Mortality = [Observed Mortality Rate-adjusted Expected Mortality Rate (x100)] x Overall Mortality Rate in the standard population.

Alternatively risk-adjusted Mortality can be calculated directly from parameter estimates from a multivariable risk-adjusted model examining data from individual institutions or from multiple institutions.

Note: Standard population refers to a population of institutions under evaluation (e.g., institutions contributing data to a national trauma registry or centrally collected administrative data bank).

Standard of Comparison

External comparison at a point in, or interval of, time

Internal time comparison

Original Title

Mortality rate.

Measure Collection Name

Quality Indicators in Adult Trauma Care

Measure Set Name

Hospital Indicators

Submitter

Quality of Trauma in Adult Care (QTAC) Team, University of Calgary - Academic Institution

Developer

Quality of Trauma in Adult Care (QTAC) Team, University of Calgary - Academic Institution

Funding Source(s)

The project was supported by a Partnerships in Health System Improvement Grant (PHE-91429) from the Canadian Institutes of Health Research and Alberta Innovates Health Solutions. Funding sources had no role in the design, conduct, or reporting of this study.

Composition of the Group that Developed the Measure

  • Dr. H. Thomas Stelfox, Principal Investigator, University of Calgary
  • Dr. Maria-Jose Santana, Co-investigator, University of Calgary
  • Diane Lorenzetti, Library Science, University of Calgary
  • Jamie Boyd, Research Coordinator, University of Calgary
  • Nancy Clayden, Research Assistant, University of Calgary
  • Colleen M. Sharp, Research Assistant, University of Calgary

Expert Panel

  • Dr. Mark Asbridge, Faculty Member, Dalhousie University
  • Dr. Chad G. Ball, Fellowship in Trauma, Critical Care and Hepatobiliary Surgery, Calgary
  • Dr. Peter Cameron, Professor and Head of Critical Care Division, Head of Victorian State Trauma Registry, Associate Director of National Trauma Research Institute, Melbourne, Australia
  • Diane Dyer, Consultant, Alberta Health Services
  • Dr. Louis Hugo Francescutti, Past President of Royal College of Physicians and Surgeons of Canada, Professor, University of Alberta
  • Marie Claire Fortin, Clinical Registries Manager, CIHI and Faculty Member, University of Toronto
  • Dr. Ken Jaffe, Professor of Rehabilitation Medicine and Adjunct Professor of Pediatrics and Neurological Surgery, University of Washington School of Medicine
  • Dr. Andrew W. Kirkpatrick, Past President Trauma Association of Canada, Professor of Critical Care Medicine and Surgery, University of Calgary
  • Dr. John Kortbeek, Professor and Head of Department of Surgery, University of Calgary
  • Dr. Karen Kmetik, Vice President of Performance Improvement American Medical Association
  • Dr. Lynne Moore, Assistant Professor of Epidemiology/Biostatistics, Laval University
  • Dr. Avery Nathens, Canada Research Chair in Trauma Systems Development, Professor of Surgery, University of Toronto
  • Dr. Nick Phan, Division of Neurosurgery, University of Toronto
  • Dr. Fred Rivara, Seattle Childrens Guild Endowed Chair in Pediatrics, Professor in Pediatrics, University of Washington
  • Bryan Singleton, Senior Manager for Emergency Health Services, Paramedic, Alberta Ministry of Health and Wellness
  • Dr. Marc Swiontkowski, CEO of TRIA Orthopedic Center, University of Minnesota
  • Dr. John Tallon, Past President Trauma Association of Canada, Associate Professor of Emergency Medicine and Surgery, Dalhousie University
  • Dr. Andrew Travers, Medical Director of Nova Scotia Emergency Medical Systems, Assistant Professor, Dalhousie Emergency Department of Medicine
  • Dr. Dave Zygun, Associate Professor of Critical Care Medicine, University of Calgary
  • Dr. Tom Noseworthy, Professor of Health Policy and Management, University of Calgary
  • Dr. Sharon Straus, Canada Research Chair in Knowledge Translation, University of Toronto

Financial Disclosures/Other Potential Conflicts of Interest

The project was supported by a Partnerships in Health System Improvement Grant (PHE-91429) from the Canadian Institutes of Health Research and Alberta Innovates Health Solutions. Dr Stelfox was supported by a New Investigator Award from the Canadian Institutes of Health Research and a Population Health Investigator Award from Alberta Innovates Health Solutions. Funding sources had no role in the design, conduct, or reporting of this study. The authors declare no conflicts of interest.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2013 Jan

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

Source(s)

Guide to quality indicators in adult trauma care. Version 3. Calgary (AB): Quality of Trauma in Adult Care, University of Calgary; 2013 Jan 29. 129 p. [111 references]

Measure Availability

Source available from the Quality of Trauma in Adult Care (QTAC) Web site External Web Site Policy.

This work is also available from the Annals of Surgery Web site External Web Site Policy: Santana MJ, Stelfox HT, Trauma Quality Indicator Consensus Panel. Development and evaluation of evidence-informed quality indicators for adult injury care. Ann Surg. 2014 Jan;259(1):186-92.

For more information, contact QTAC at the University of Calgary, Teaching Research & Wellness (TRW) Building, 3rd Floor, 3280 Hospital Drive NW, Calgary, AB, Canada, T2N 4Z6; Phone: 403-944-2334; Fax: 403-283-9994; E-mail: qtac@qualitytraumacare.com; Web site: www.qualitytraumacare.com External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on May 11, 2015. The information was verified by the measure developer on July 13, 2015.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

The individual measures from the "Guide to Quality Indicators in Adult Trauma Care," are available from the Quality of Trauma in Adult Care (QTAC) Web site External Web Site Policy.

For more information, contact Tom Stelfox, MD, PhD, at the University of Calgary, Teaching Research & Wellness (TRW) Building, 3rd Floor, 3280 Hospital Drive NW, Calgary, AB, Canada, T2N 4Z6; Phone: 403-944-2334; Fax: 403-283-9994; E-mail: tstelfox@ucalgary.ca.

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