Traumatic Brain Injury Quality Improvement for
Pre-Hospital Providers: A Pilot Project
Giles Gifford, EMT
Project Coordinator
Monica S. Vavilala, MD
Project PI
Giles Gifford, EMT
Paddy Downey, EMT
Traumatic Brain Injury (TBI)
 Leading cause of morbidity and mortality
 Yearly 1.7 million people sustain TBI
 ~1.36 million are treated in ED and discharged
 275,000 hospitalized
 80,000 to 90,000 disabled
 52,000 die
 5.3 million (~ 2%) are living with TBI disability
 ~1% of severe TBI survive in a persistent vegetative state
 In 2000, estimated lifetime direct medical costs and indirect costs (e.g., loss of
life long productivity) from TBI = 76.5 billion dollars
National TBI Guidelines
 BTF (2007)
 Evidence based guidelines for severe TBI care
 Pre-hospital component
 Pre-hospital care assessment, treatment and transport
guidelines separated into 7 areas (ALS and BLS)
 PHTLS
 One didactic chapter
TBI Care Protocols in WA State
 No state TBI protocol specific for TBI
 Two EMT-B (BLS) protocols
 Adherence required by DOH for all 39 counties


General trauma assessment
Head and spine injury
 No standard EMT-P (ALS)
 County MPD decides protocols for assessment,
treatment and transport
Current WA State CME
 State
 DOH has EMT-B protocols in place
 County
 MPD decides how EMTs maintain certification


OTEP – Ongoing Training and Evaluation Program
 Competency based - no set number of hours per year
 Series of topics (Cardiac, OBGYN etc.)
 Given by MD or certified trainer in person or video recording
 Cognitive/written exam
 Practical portion to demonstrate proficiency
EMS online – online educational modules with case studies,
written exam and in person practical skills assessment
 Accreditation
 EMTs must recertify every 3 years
 No current TBI module
Problems
 No uniform guidelines
 Pre-hospital education
 Lack of benchmarking
 Adherence to national guidelines unclear
 HIPRC Aims
 Examine current TBI Education
 Present techniques to improve TBI care
Project Overview
Year 1 (2010-2011): Benchmarking and Education
 Do we adhere to national guidelines in WA State ?
 Can we develop a training module for state ?
Year 2 (2011-2012): Development and Pilot TBI QI Bundle
 What TBI QI processes exist nationally ?
 Develop the QI bundle (module, documentation, cases)
 Pilot the QI bundle
 Evaluate QI bundle effectiveness
County Adherence:
Oxygenation and Blood Pressure
BTF Guidelines
Yes
(n=23)
No
(n=23)
Some
(n=23)
Monitor for hypoxemia
(SpO2 < 90% )
2 (9%)
9 (39%)
12 (52%)
Monitor for hypotension
SBP < 90 mmHg for age > 13 yrs
4 (17%)
8 (35%)
11 (48%)
Assess oxygenation every 5 min.
Continuous monitoring if possible
1 (4%)
14 (61%)
8 (35%)
Assess BP every 5 minutes.
Continuous monitoring if possible
1 (4%)
12 (52%)
10 (44%)
Total counties = 39
7 No ALS providers, 9 No TBI elements
Year 1 Summary
Benchmarked WA State ground, county ground, and air
ambulance protocol language and content
2. Learned pre-hospital providers want more TBI education
3. Delivered
1.
1.
2.
3.
4.
ppt module to DSHS for dissemination
DOH approved module for CME
Module posted on EMS online
Module posted on HIPRC website
Year 2 Aims (2011-2012)
Develop TBI QI bundle
1.
2.
3.
Educational module
Score PCRs using TBI audit tool
In –person case discussions
Pilot and Evaluate TBI QI Bundle
1.
2.
2 rural and 2 urban counties
Outcomes
1.
Change in


2.
PCR documentation of TBI indicators pre and post bundle
(audit score)
Pre and post education test score (knowledge)
Pre-hospital provider satisfaction
Evaluation of WA State Pre-Hospital QI Process
 No written template for QI process
 QI at county level, under MPD direction
 Board


5-6 members selected by MPDs
 ER nurses, paramedics and other physicians
 Confidentiality agreement
Meets 1 to 2 times/ year to review EMS patient care
reports (PCR's) focusing on area of review
Development of Audit Tool
 Research existing written pre-hospital TBI QI processes
 Internet search of state, county, municipality protocols US
 Found 4 with written templates addressing some TBI
elements

NY (State), CA (County), PA (Pittsburgh), FLA (Miami)
 Selected “poorly faring or important” WA state indicators
for benchmarking
20 Audit
Tool Indicators:
 Mechanism of injury
• Antecedent events
• Kinematics
• Witness accounts
 C-Spine precautions
 Hypoxia prevention
 Intubation indicators
 TBI signs and symptoms
 Serial capnography values
 Loss of consciousness
 Post intubation RR
 Serial Vital Signs - Q5
 IV fluid initiation
 Serial GCS scores – Q5
 Glucose value
 Pupillary exam – Q5
 Transport decisions
 ETOH/ drug use
14
Score 1 = complete documentation of indicator
Maximum = 20 ALS, 16 BLS, 11 No Transport
Recruitment of Counties
 WEMSIS considered
 Electronic data capture with pre-collected indicators of “head trauma”
 System capabilities and state contributions
 Direct recruitment
 MPD list of contacts



Email invitation
Phone project introduction
Scheduled in person training
 QI Bundle



Before training, each MPD sent ~20 PCRs to HIPRC
Training
1. Audit tool introduction
2. Baseline county results
3. Pre-test
4. Education module
5. Case study
6. Post test
7. Satisfaction survey
Second set of PCRs due 6 months after training
County Enrollment
Email List to 39 County MPDs
Response Rate (n=15; 38%)
Phone Call (n=11; 28%)
Sent PCR’s & Scheduled Training (n=10; 26%)
Training Complete (n=10; 26%)
5/20 High Risk Counties
5/19 Low Risk Counties
PCR Review Sample
 84% electronic
 16% paper
 Electronic PCRs more
indicators than paper
 Paper PCR
 Too much free text
 Data fields not
prompted
PCR Review
 Associated with pictures
 May be helpful to understanding mechanisms
198 PCRs From 10 Counties (2008-2011)
Total Score Possible
20
Total Score
Possible: 20
Average
Total Score
Possible: 16
15
Total Score
Possible: 11
10
5
0
ALS
BLS
• Room for improvement
No Transport
Number of 10 Counties with Poor (0-49%)
Documentation on PCR (n= 198)
 10: GCS reassessed every 5 minutes
 10: Pupil reassessment
 9: VS reassessment every 5 min
 9: Glucose check
 9:Capnography used after ETT with serial readings
 8: Pupil examination with component parts
 5: ETT ventilation rate supported
 3: ETOH or drug use
 3: Post tracheal intubation RR documented
 2: Completed vital signs
 1: GCS with component parts
Outreach: Module & Case Discussion
 12 site visits to 10 counties:
 2 counties requested 2
 A total of 190 EMS personnel attended:
 County MPD, all EMT levels, county training coordinators,
ER triage nurse, county EMS directors
Pre & Post Training Quiz
1. Same 10 question quiz to
assess effectiveness
2. Questions based on need





Signs & symptoms (3)
GCS (3)
Ventilation (2)
Cerebral herniation (1)
Transport decisions (1)
3. Satisfaction survey
Overall Pre and Post Test Score Change
P < 0.0001
Question 6 - GCS
(True/False) “Squeeze my hands” counts as obeying a verbal command
1
0.9
0.8
0.7
Score
0.6
0.5
0.4
0.3
0.2
0.1
0
Total
Pre-test ~ 8%
Post-test ~ 89%
Question 8 - Ventilation
Patient presents with extensor posturing, fixed dilated pupils, SpO2 90%,
EMT –P should:
A) Intubate and hyperventilate
B) Intubate and normoventilate
C) Administer 25 Liters/min. non-rebreather mask
0.8
0.7
0.6
Score
0.5
0.4
0.3
0.2
0.1
0
Total
Pre-test ~ 17%
Post-test ~ 73%
Documented Improvement
 Signs and symptoms scores increased for all questions
 GCS familiarization increased for all questions
 Cerebral herniation recognition increased by 9%
 Knowledge of appropriate transport decisions increased 10%
Change in Test Scores By County
57%-79%
46%-73%
61%-72%
55%-57%
62%-78%
55%-71%
55%-81%
73%-88%
49%-78%
55%-86%
= Counties with greatest improvement
Follow up with MPDs
Emailed
1. Audit scores a week after site visit
2. Training module
3. Audit tool for use
Training Satisfaction (n = 190)
= Yes
= Neutral
= No
= No Response
Comments from EMS and MPD
 EMTs
 Good to stress GCS scores because they don’t get used enough
 Great review and good reminders of what we need to be looking for
Always a good thing to review and keep current on, great job
 Very informative and provided new thoughts about head trauma
 QI audit tool is a good tool to add to the patient report chart
 MPDs
 Practical aspect to training BLS to ALS Handoff
 No N/V, dizziness stressed in training
Year 2 Lessons Learned
1. Counties want this training (recruited 10, not 4)
2. Pre-hospital setting may benefit from a QI process
3. MPDs are willing to participate
Next Steps
 Obtain follow up PCRs from counties
 Filter these reports through audit tool
 Report areas of improvement
 Especially in areas with low adherence
 Publish process and findings
 Dissemination and Implementation study
Whatcom County EMS/TC Council’s
31st Annual Conference on Pre-Hospital Medicine
October 26-28, 2012, Bellingham WA
Friday, October 26, 2012
3:20 – 4:20 Traumatic Brain Injury, Patty Downey
1. TBI is a leading cause of morbidity and mortality in
Washington State.
2. EMS of all levels play an important role in the detection
and treatment of TBI.
3. Early recognition and timely management of TBI by
emergency medical personnel is essential
4. Please join us for a CME training based on the Brain
Trauma Foundation’s guidelines for the prehospital
TBI management
Acknowledgements of Study Partners
Agencies
 DSHS
 DOH
 BIAWW
 EMS On-line
 State Counties
People
 Mike Lopez
 Kathy Schmidt
 Terry Redmon
 Deborah Crawley
 Deepak Sharma
 Charles Mock
 Eileen Bulger
 Mickey Eisenberg
Acknowledgements of Participating
County MPDs & Staff
 Dr. Sandra Smith-Polling
 Steve Gordon Palmeroy
 Colleen Rodriguez
 Dr. Michael Luce
 Richard Naumann
 Dr. Russell Smith
 Mark Bryan
 Bob Gwynn
 Dr. Marvin Wayne
 Sean Farnand
 Dr. Terry Murphy
 Dr. Lance Jobe
 Rinita Cook
 Dr. Don Slack
 Dr. Patrick O’Neill
 Dr. Michael Sullivan
 Mik Preysz
 Patrick Shelper
Last slide
Results for Oxygenation and Blood
Pressure Across all 7 BTF Indicators
• State level EMT-B protocol (n=1):
• 2 indicators partially matched
• 5 did not match
• % Counties of n=23 that matched on 7 BTF indicators:
• Fully= 0-17%
• Partially = 0-48%
• None = 35-100%
Year 1: Pre-Hospital Focus Group Results
 Current CME methods well liked
 Most EMTs they had knowledge of triage/transport criteria
 50% felt adequately prepared to treat TBI but were not
familiar with their county protocol
 Wanted more education on
 Secondary insults
 GCS
 Elderly needs
 Symptom recognition
 Altered LOC

ETOH
 Concussion
Year 1: Module Development
 ALS
 http://depts.washington.edu/hiprc/Education%20and%20Tra
ining/EMS%20Training%20Module/PART3A.ALS.PPT.pdf
 BLS
 http://depts.washington.edu/hiprc/Education%20and%20Tra
ining/EMS%20Training%20Module/Part3-B.BLS.PPT.pdf
County
Risk
PCR –No
Transport
X/11
PCR BLS
X/16
PCR –ALS PCR – ALS
NO ETT
ETT
X/17
X/20
Pretest
Average
Posttest
Average
Whatcom
High
5.8/11
7.6/16
n=7
11.6/17
57%
79%
N/A
11.8/17
61%
72%
46%
73%
62%
78%
55%
57%
55%
71%
55%
81%
73%
88%
55%
86%
49%
78%
n=6
Skagit
High
N/A
13.2/20
n=10
n=6
10/20
n=17
San Juan
Low
4.4/11
n=9
Jefferson
High
5/11
n=1
Chelan
Low
N/A
10.5/16
n=1
12/17
11.5/16
n=2
11.2/17
N/A
13.1/17
n=3
17/20
n=9
n=1
13/20
n=11
n=7
13.3/20
n=7
Douglas
Low
N/A
N/A
13.1/17
n=5
13.3/20
n=7
Grant
Lewis
Klickitat
Columbia
High
High
Low
Low
N/A
N/A
N/A
N/A
N/A
n=5
12.3/17
n=20
15.1/20
4.5/16
n=1
11.1/17
14.7/20
10.7/16
n=3
11.8/17
n=13
14.5/20
10.8/16
n=12
12.1/17
8/20
n=4
n=17
n=6
n=5
n=2
n=1
Year 1 Aims
1. Examine WA state language and content adherence to
national guidelines for severe TBI
2. Examine needs and opportunities for pre-hospital TBI
education
3. Develop a pre-hospital curriculum for TBI in WA state
Year 1 Methods

Benchmarking against 7 BTF areas, each with multiple
recommended indicators
1.
2.
3.
4.
5.
6.
7.

Assessment: Oxygenation and Blood Pressure
Assessment: Glasgow Coma Scale Score
Assessment: Pupil Examination
Treatment: Airway, Ventilation and Oxygenation
Treatment: Fluid Resuscitation
Treatment: Cerebral Herniation
Transport: Transport decisions
Focus groups, phone interviews and written surveys

EMTs in each county
 BIAWW EMS conference
 Educational module
Year 1 Benchmarking Results
 Of 39 counties in WA State
 7 (18%) do not have any ALS protocols for anything
 9 (23%) have ALS but not specific “head trauma or
TBI” protocols
 23 (59%) have ALS and addresses “head trauma or
TBI” components
BTF Assessment Example:
Oxygenation and Blood Pressure
• Each indicator compared with current WA State EMT-B TBI
protocols, WA State county ALS TBI protocols and two private
air ambulance companies
• Indicator adherence at the state, county and air ambulance
company level
• Protocols grouped as meeting BTF guideline
recommendations:
• All = meets all
• Some = meets some
• None = matches none
Part 1-B Literature Review
 A Pub Med search was conducted with key words TBI
and prehospital – 207 results
 Excluded results prior to March 2007
 Excluded editorials
 Pediatric and Animal studies excluded
 7 studies remained relevant
 6 had findings concurrent with the BTF guidelines
 1 study advocated slightly different acceptable PaCO2
levels
PCR Review
•Electronically written PCR
•Every data field is prompted
PCR Review Results
 Received 201 PCRs from 10 different counties








Lewis Co. n=22, range 28%-88%, median 66.5%
Skagit Co. n=20, range 30% - 88%, median 65%
Grant Co. n=24, range 59%-88%, median 71%
Jefferson Co. n=22, range 53%- 88%, median 69%
Whatcom Co. n=29, range 36%-81%, median 59%
Klickitat Co. n=18, range 56%-88%, median 69%
Columbia Co. n=19, range 40%-82%, median 69%
Chelan & Douglas Co. n=24, range 48%-91%, median 75%
 1 MPD for both counties
QI National Review
 Using established Washington Emergency Services Information




System (WEMSIS) data base indicators and the BTF guidelines, a
TBI QI Audit Tool was developed to evaluate EMS head trauma
responses from participating agencies throughout the state.
This was compared nationally to other QI processes that
included head trauma at the state, county and city government
levels
At the State Level - New York has published the only
comprehensive quality improvement document complete with
sample audit tools.
California has QI Audit Tools and guidelines at the County level
EMS councils from the cities of Pittsburg and Miami have
published QI Audit Tools and Guidelines
Question 1 – Signs and Symptoms
The following are signs and symptoms of ETOH and not Traumatic Brain Injury
A) Slurred speech, vomiting, loss of coordination
B) Dilated pupils, convulsions, diminished consciousness
D) All of the above
E) None of the above
Question 2 – Signs & Symptoms
(True/False) Hypoxia and hypotension are recognizable
and preventable causes of secondary brain injury?
Question 3 – Signs & Symptoms
(True/False) Tachypnea, tachycardia, change in level of consciousness,
and cyanosis are all signs of shock but not hypoxia?
Question 4 - GCS
(True/False) – The motor component of the GCS focuses only on the
upper extremities?
Question 5 - GCS
What is the GCS score for a patient whose eyes open to pain, withdraws
from painful stimuli, and makes inappropriate sounds?
A) 3 + 4 + 3 = GCS of 10 (moderate TBI)
B) 3 + 3 + 3 = GCS of 9 (moderate TBI)
C) 2 + 4 + 2 = GCS of 8 (severe TBI)
Question 7 - Ventilation
(True/False) Prophylactic hyperventilation - (PaCO2 < 35 mm Hg)
should be initiated for every severe TBI patient
Question 9 – S&S Cerebral Herniation
All of the following are signs/symptoms of cerebral herniation except
A) Dilated pupils
B) Extensor posturing
C) Cyanosis of the fingernails and lips
D) Cushings Triad
Question 10 – Transport Decisions
Patients with severe TBI should be transported to a facility with immediately availiable
A) CT scanning
B) Prompt neurosurgical care
C) The ability to monitor ICP
D) Two of the above
E) All of the above
Training Satisfaction (n = 190)
Question
1 = Agree 2 = Neutral
3 = Disagree
No
Response
Did you find the training
115
useful to your knowledge or
practice?
(60%)
7
9
59
(4%)
(5%)
(31%)
Did you learn how to better 105
assess treat or transport
TBI patients?
(55%)
14
11
60
(7%)
(6%)
(32%)
Would you recommend this 111
training to your colleagues?
(58%)
8
11
60
(4%)
(6%)
(32%)