3.1 Direct Admission to ED Shock Room

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Description of Indicator

Relationship to Quality  Medical care should be timely 
Type of Indicator Hospital process, Hospital level
Proposed Data Source ED Records
Definition Number of injured patients with physiological compromise* directly admitted to ED shock room (trauma/resuscitation) per 100 ED admissions 
Numerator All injured patients age 18 years and older with physiological compromise* AND admission to the ED shock room (trauma/resuscitation) in 10 minutes or less of ED arrival
Denominator All injured patients age 18 years and older with physiological compromise* admitted to the ED 
Benchmark Not specified at present
Risk Adjustment Not applicable

* Proposed parameters of physiological compromise (RR < 10 or >29 breaths per minute or intubated or GCS < 9 or SBP < 90 mmHg) are derived from the field triage published by the CDC9,10. They are designed to provide simple identification of patients with physiological compromise that may benefit from direct admission to the ED shock room, but can be replaced by local guidelines if available.


Summary
This indicator is intended to monitor whether injured patients with physiological compromise are directly admitted to ED shock rooms.


Panel Review
Panelists indicated that the decision to use the shock or trauma room is part of basic triage of a trauma patient and that the indicator could be used to ensure that the right patients get to the right place in the ED. It was suggested that physiological criteria could be used to identify patients that may benefit from early admission to the ED shock room. Panelists advocated that the indicator may be valuable to examine any association between ED ‘overcrowding’ and patient care as well as to assist in further defining which patients are most likely to benefit from direct trauma/shock room admission.
Concerns relating to feasibility and documentation were brought forward by the panelists. They noted that hospitals might have very different local guidelines that may significantly impact ED triage decisions.


Trauma Center Review
The trauma centers emphasized that having resources available and accessible for compromised patients is essential and compliance for this indicator should be 100%. The trauma centers noted that some organizations already use similar measures and therefore the definition should be consistent with previously established guidelines (e.g. ASCOT)2. The trauma centers indicated that “ED Shock Room” must be explicitly defined to ensure a consistent application of the indicator. The question was raised about how patients who receive appropriate treatment in another location in the ED other than the shock room should be handled. The trauma centers were concerned about reliability and validity of medical record documentation required for the indicator.


Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study demonstrated that implementation of a trauma quality improvement program that included the quality indicator was associated with reduced hospital mortality35.
Reliability: No studies identified.
Risk Adjustment: Not applicable.
Utilization: The indicator does not appear to be currently used by trauma centers: USA 0% (0/200), Canada 0% (0/35), Australasia 0% (0/12).

 

Source
The quality indicator was proposed by Ruchholtz et al.35.

 

References
2. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient 2006. Chicago: American College of Surgeons; 2006.
9. Centers for Disease Control and Prevention (CDC). CDC - Injury Prevention and Control: Field Triage - Guidelines for the Field Triage of Injured Patients. 2011; http://www.cdc.gov/fieldtriage/index.html. Accessed July 8, 2012.
10. Sasser SM, Hunt RC, Sullivent EE, et al. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep. 2009;58(RR-1):1-35.
35. Ruchholtz S, Waydhas C, Lewan U, et al. A multidisciplinary quality management system for the early treatment of severely injured patients: implementation and results in two trauma centers. Intensive Care Med. 2002;28(10):1395-1404.