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TRAUMA QI & PEER REVIEW. Katrina Strowbridge, BSN, RN, CWS. How’s it happen?. Why a review process?. Trauma Designation Organized trauma program required for all levels of designation to include: Multidisciplinary trauma committee Trauma Peer Review (with multidisciplinary committee)

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Presentation Transcript
trauma qi peer review


Katrina Strowbridge, BSN, RN, CWS

How’s it happen?

why a review process
Why a review process?

Trauma Designation

Organized trauma program required for all levels of designation to include:

Multidisciplinary trauma committee

Trauma Peer Review (with multidisciplinary committee)

Performance Improvement activities related to the findings of chart review and Peer Review

whatsa multidisciplinary committee
Whatsa“Multidisciplinary Committee”???


  • RN’s
  • MD’s
  • Support Staff
  • Prehospital Providers

Trauma Committee


so how do ya do peer review of trauma cases
……so, how do ya do peer review of trauma cases….

Multidisciplinary Trauma


is NOT

the Medical Staff

Peer Review Committee

new process
New Process

Case Selection for record review:

Record Selection via Daily Rounds

Trauma Coordinator gleans information from staff

Trauma Registrar review of ED log

ER charge review by RN

Chart identified by staff, physicians, department, etc

Meditech reports – ICD-9 diagnosis codes & discharge disposition

focusing on discharge disposition
Focusing on: Discharge Disposition

Treated and discharged home or transferred

Identified via daily review as described

If immediate concerns, reviewed by TC and Trauma Medical Director/Chief of Staff

If no immediate concerns, coded by HIM

Record reviewed by TC and TR using a review worksheet.

discharge disposition cont
Discharge Disposition cont.

Treated and Admitted to IP or OPO

Identified via daily reviews as described

Allows for concurrent review with more immediate documentation available in the form of progress notes, physician orders, H&P, etc.

Immediate concerns reviewed with Trauma Medical Director/Chief of Staff

case identified review begins
Case identified, review begins

Trauma Committee Case Review


PI form used to abstract record

Indicators approved by Medical Staff & Trauma Committee

Tracks key indicators used for QI processes

Developed from samples received from other CAH’s & WRTAC sample forms.

Driving force for data collection of trauma related QI activities and documentation source for the review process.

case review types drive process
Case Review “types” drive process
  • Primary Review
  • Secondary Review
  • Tertiary Review
primary review
Primary Review
  • Trauma Registrar
    • Initiates Trauma Committee Review form for each case reviewed
    • Forwards patient record and TCR form to Trauma Coordinator
  • Trauma Coordinator
    • Review record, validates findings, finds new issues
      • Immediate resolution, feedback with identified issues & documentation of PI loop closure
secondary review
Secondary Review
  • Trauma Coordinator reviews/validates findings, finds new issues
  • Medical Staff review of identified issues, supports investigation and assists in plan development
    • 1:1 education (any discipline {RN: RN, MS: MS}, group education @ TC
    • May be closed at this level or forwarded for further action based on findings
    • Refer to Multidisciplinary Trauma Committee or Medical Staff Peer Review Process
tertiary review
Tertiary Review
  • Trauma Coordinator & Medical Staff/Peer Review
  • WRTAC &/or STAC
    • Findings documented in PI loop closure
    • Education may still be 1:1, generally group @ large via Trauma Committee or regional efforts if required
clinical indicator report
Clinical Indicator Report
  • Trauma Registrar is responsible for completion of and reporting of data
  • Data pulled from Trauma Committee Case Review form
  • Entered into Clinical Indicator Report
  • Clinical Indicator Report shared with Trauma Committee
  • Used for ongoing monitoring
  • Identification of trends and issues
peer review

Peer Review

Confidential – confidential – confidential – confidential – confidential –


peer review process
Peer Review Process

It is important that providers feel “safe” giving honest feedback to colleagues and this trust environment takes time to establish. The providers also need to feel empowered by Administration to tackle hard issues, require changed behaviors and performance of some peers and be able to hold colleagues accountable.

trauma committee peer review process
Trauma Committee Peer Review Process

Trauma Coordinator is responsible for

setting up the Trauma Peer Review Committee meetings,

obtaining the charts,

Keeping the Trauma Committee Case review form with the chart and initiating peer review form,

engaging in discussion regarding any issues,

transcribing the confidential feedback,

participating in any performance improvement activity that may be initiated as a result of the

peer review worksheet
Peer Review Worksheet

Form developed to assist the physicians when performing chart review.

Issue - Physicians are made aware of the reason the chart has been brought to the Peer Review Committee. In reviewing the chart, other issues may be identified as well.

Findings - The reviewing physician documents findings

Confidentiality – issues are later transcribed into a confidential report that is forwarded to the provider involved in the care of the patient.


Once review is completed, forms routed to Trauma Registrar

A unique identification number is assigned

Entered into the Trauma Committee log book

A individual file is created

Feedback reports filed from Medical Staff & Trauma Peer Review

recordkeeping cont
Recordkeeping cont.

State Trauma Registry abstraction

Assigned a different number (with the TC#)

Entered into the State Trauma Registry log book.

Feedback reports from the State & abstract are all filed in the Trauma Committee file for future reference.


Contact information

Leah Emerson, RN, DON, TC


Katrina Strowbridge, RN, QI Coordinator, TR