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TQIP Basics for TMDs and TPMs: Orientation to reports & drill down tools Avery Nathens, MD, PhD, FACS

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Objectives • How to get the most out of your reports • When and how to drill down to get more

information • How to use TQIP to complement your PI

program • More details in “Reading between the

lines”

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Report contents

• Facility characteristics • Aggregate patient/injury

characteristics • Risk adjusted analysis

• Mortality • LOS

• Contextual analysis on patient cohorts

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Contextual analysis • Informative data presented by center to understand

how care is delivered for specific types of patients

TBI ICP monitoring

Tracheostomy timing Timing of death (withdrawal of care)

Elderly Timing to OR for Rx of hip fractures Timing of death (withdrawal of care)

Pelvic fractures Use of angiography

Shock (Time to hemorrhage control) (Transfusion practices)

Isolated blunt splenic injury Splenic preservation Angiography LOS – ICU, hospital

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Obs

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ratio

expected line

point

Confidence interval

O/E < 1

Better than expected

O/E > 1

Worse than expected

Caterpillar graphs Risk-adjusted outcomes

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Caterpillar graphs Risk adjusted outcomes

Odd centers

Even centers

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Use the data to tell a story TBI Mortality

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Excess length of stay

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ICP monitoring

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Time to death

Are we providing futile care?

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Tracheostomy practices in TBI

Disposition after Tracheostomy

Do we have a problem with end of life care?

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TQIP Online • Secure site for data drill down • Patient lists for investigation of patients in TQIP

to help explain outcomes and TQIP results

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TQIP participant portal www.acstqip.org

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TQIP Online Patient Lists

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TQIP Patient Lists • Every patient record submitted to TQIP

• Patient/injury characteristics • Ensure the data we have is what you have

• Discharge status • Alive/dead • TQIP probability of survival

• Identifies unexpected survivors or deaths • Guides your PI process

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Accessing your patient lists

Click on a patient ID to see more

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Patient details

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Individual patient

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Export data for further analysis

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TBI report Patient ID Age Lived / Died Estimated probability

of death (%)

15476 17 LIVED 0.19 23645 17 LIVED 0.21 55555 21 LIVED 0.22 32112 32 LIVED 0.24 12421 21 LIVED 0.49 15734 31 LIVED 0.64 42157 43 LIVED 0.65 24125 45 LIVED 0.66 34512 51 LIVED 0.67 11221 45 LIVED 0.67 12412 46 LIVED 0.68 21453 64 LIVED 0.73 12345 45 DIED 0.8 54781 26 LIVED 0.8 63521 47 LIVED 0.81

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Unexpected death

• 45 yo male, transferred in after a fall • No trauma team activation • SBP 134, HR 110, RR 18, T 37, GCSm 6 • Small subdural, small contusion and

subgaleal hematoma • Awaiting disposition • Cardiac arrest without return of cardiac

function

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TBI report

Patient ID

Age Lived / Died

Probability of Death TBI

12999 78 LIVED 10.07 21125 74 LIVED 10.12 32115 83 LIVED 10.23 12451 56 LIVED 10.26 21212 17 DIED 10.8 13178 79 LIVED 11.17 11182 78 LIVED 11.21 27531 27 LIVED 11.24 23755 83 LIVED 11.33

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Unexpected death • 17 yo, fell hit head, transferred in from

elsewhere • SBP 135, HR 45, T 34.5, GCSm 3 • No trauma team activation • CT ~45 min after arrival – blew pupil

• Epidural hematoma • Evacuated • Large PCA infarct postop

• Care withdrawn

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Shock report Patient ID Age Lived /

Died Probability of Death

Shock 13331 34 LIVED 22.53 13214 20 LIVED 45.8 21341 28 DIED 48.57 15423 28 DIED 56.22 25252 54 LIVED 57.46 23232 55 DIED 61.85 32324 41 DIED 74.89 12129 39 LIVED 78.38 19874 27 DIED 79.61 19751 82 DIED 85.91 17922 83 DIED 91.25 18678 62 DIED 95.36 54218 62 DIED 95.6

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Unexpected survivor • 39 yo male, run over by garbage truck, transported

by land with an ED SBP of 58 on a Monday morning

• Bilateral pneumo, pulmonary contusions • Sternocostal dissociation, multiple rib fractures, • Splenic & liver laceration - laparotomy, packed • Pelvic fracture, extraperitoneal packing + angio • Extraperitoneal bladder rupture • Extensive degloving abdominal wall, left groin,

lower extremity • Traumatic AKA

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Unexpected survivor

• Massive transfusion protocol activated • Within a few hours: 32u RBC’s, 24 u FFP’s,

cryo, platelets • Guided by frequent labs & input from

transfusion medicine

• Why did he survive? • Transfusion medicine is a weekday service

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Process evaluation • Virtually impossible to compare practices

across institutions without data • Challenging to effect change without

knowledge of where you stand • Timing of fracture fixation • ICP monitoring • Use of angiography

• Evaluate practice in relation to outcome • e.g. timing of tracheostomy & pneumonia

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Summary

• Data from TQIP reports can be used as a “dashboard warning light” • There is a problem, but where??

• There is more to TQIP reports than the data in the tables and graphs • Use the data to tell a story

• TQIP online can complement your existing PI processes

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Summary

• Drill downs at the patient level should complement your existing PI processes • Identify unexpected deaths

• Evaluate the other end of the bell curve – unexpected survivors • A source of positive feedback for the team • Identify factors that lead to favorable

outcomes

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Summary

• Drill downs provide good overview of your patients and practices

• Practice evaluation a major component of a drill down

• Practices evolve as a result of many factors • Resources • Right people • Tradition • Patients

• Drill downs at the patient level should complement your

existing PI processes • Identify unexpected deaths