How’s it happen?
Katrina Strowbridge, BSN, RN, CWS

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Trauma Designation
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Organized trauma program required for all levels of designation to include:
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Multidisciplinary trauma committee
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Trauma Peer Review (with multidisciplinary committee)
Performance Improvement activities related to the findings of chart review and Peer Review

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RN’s
MD’s
Support Staff
Prehospital Providers
= Trauma
Committee
………..right?

Multidisciplinary Trauma
Committee is NOT the Medical Staff
Peer Review Committee
……so, how do ya do peer review of trauma cases

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Case Selection for record review:
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Record Selection via Daily Rounds
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Trauma Coordinator gleans information from staff
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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

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Treated and discharged home or transferred
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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.

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Treated and Admitted to IP or OPO
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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
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Trauma Committee Case Review
Worksheet
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PI form used to abstract record
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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.

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Primary Review
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Secondary Review
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Tertiary Review

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Trauma Registrar
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Initiates Trauma Committee Review form for each case reviewed
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Forwards patient record and TCR form to Trauma
Coordinator
Trauma Coordinator
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Review record, validates findings, finds new issues
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Immediate resolution, feedback with identified issues & documentation of PI loop closure

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Trauma Coordinator reviews/validates findings, finds new issues
Medical Staff review of identified issues, supports investigation and assists in plan development
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1:1 education (any discipline {RN: RN, MS: MS}, group education @ TC
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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

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Trauma Coordinator & Medical Staff/Peer Review
WRTAC &/or STAC
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Findings documented in PI loop closure
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Education may still be 1:1, generally group @ large via Trauma Committee or regional efforts if required

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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

Confidential – confidential – confidential
– confidential – confidential – confidential

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.

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Trauma Coordinator is responsible for
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 setting up the Trauma Peer Review Committee meetings, obtaining the charts,
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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

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Form developed to assist the physicians when performing chart review.
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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.
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Findings - The reviewing physician documents findings
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Confidentiality – issues are later transcribed into a confidential report that is forwarded to the provider involved in the care of the patient.

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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

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State Trauma Registry abstraction
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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.

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Contact information
Leah Emerson, RN, DON, TC
406-528-5224 lemerson@stlukehealthnet.org
Katrina Strowbridge, RN, QI Coordinator, TR
406-528-5201 kstrowbridge@stlukehealthnet.org