J. D. Slocum1, J. L. Holl2, D. Jelke1, M. Anstadt3, W. Brigode4, N. Siparsky5, A. M. Stey1 1Feinberg School Of Medicine – Northwestern University, Department Of Surgery, Chicago, IL, USA 2University Of Chicago, Center For Healthcare Delivery Science, Chicago, IL, USA 3Loyola University Medical Center, Department Of Surgery, Maywood, IL, USA 4Cook County Hospital & Health System, Department Of Surgery, Chicago, IL, USA 5Rush University Medical Center, Department Of Surgery, Chicago, IL, USA
Introduction: Re-triage is the emergency transfer of severely injured patients from non-trauma or low-level to high-level trauma centers, which significantly lowers mortality rates. We sought to identify failures when receiving re-triaged patients at high-level trauma centers in a 55-hospital statewide surgical quality improvement collaborative.
Methods: We conducted a Failure Modes Effects and Criticality Analysis (FMECA) of re-triage processes at four high-level trauma centers. In phase 1, we recruited clinicians and staff involved in the re-triage process through purposive sampling of trauma coordinators at high-level trauma centers in the statewide collaborative, followed by snowball sampling to ensure representative participation of all involved disciplines at their hospital. In phase 2, we mapped each step in the process and systems of care for transfer of a severely injured patient to a receiving high-level trauma center. In phase 3, participants identified failures of each identified step and the underlying causes. In phase 4, standardized scales were used to rate each failure’s impact (I) on the patient, frequency (F), and safeguard for detection (S), A Risk Priority Number (RPN) (I x F x S) was calculated to rank order all failures by criticality. All findings were shared and validated by participants at each hospital.
Results: 22 re-triage clinicians participated in the FMECA, including trauma surgeons, emergency medicine physicians, trauma nurses and clinical quality managers. Figure 1 shows the process map of the re-triage process at the receiving hospitals; 21 steps and 178 failures were identified. The most impactful receiving hospital failure was related to transmission of images between sending and receiving hospitals. The most frequent failure was delay in transportation. The failure with the least safeguard for detection was insufficient transportation staffing. By criticality, the three most critical failures were lack of adequate staffing when transporting a patient (RPN=280); issues in transmitting images from sending hospital to receiving hospital trauma team (278); and delays in relaying information during sending and receiving physicians’ discussion (218).
Conclusion: The most critical failures occur during steps dependent on efficient information exchange between sending and receiving hospitals. Improved processes and modalities to exchange information between sending and receiving facilities is urgently needed to optimize re-triage of severely injured patients.
