3.19 Protocol for Peer Review & Reporting of Quality of Injury Care

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Description of Indicator

Relationship to Quality Medical care should be safe and effective
Type of Indicator Hospital structure, Hospital level
Proposed Data Source Survey
Definition Hospitals with multidisciplinary peer review of the quality of care provided to injured patients and reporting of quality improvement actions
Numerator Hospitals with regular*, structured‡ and multidisciplinary† peer review of the quality of care provided to injured patients age 18 years and older that includes review of adverse events and deaths AND reportingβ of resultant quality improvement actions
Denominator Not applicable
Benchmark Not applicable
Risk Adjustment Not applicable

* Regular indicates scheduled recurrent meetings more than once a year (e.g. monthly).
‡ Structured indicates an organized and systematic process that is standardized (i.e. same process each meeting).
† Multidisciplinary indicates participation of experts from the multiple patient care domains pertinent to injury management.
ß Reporting indicates that results of the multidisciplinary peer review process are summarized and resulting quality improvement actions documented and periodically reported (e.g. annual peer review report outlining improvement opportunities identified and actions taken).


This indicator is intended to identify trauma centers with regular, structured and multidisciplinary peer review and reporting of the quality of care provided to patients with injuries.


Panel Review
Panelists indicated that the indicator was designed to encourage learning opportunities for healthcare teams regarding their performance. Panelists highlighted the importance that the peer review process is multidisciplinary and incorporates relevant stakeholders (healthcare providers across the spectrum of care – paramedics, nurses, physicians of different specialties, rehabilitation experts, administrators and patient advocates). They also noted the importance of the peer review being structured to ensure that the process is somewhat standardized. In addition panelists felt that it was important to have a reporting process that summarizes the peer reviews and links them to data, so that associations between quality improvement measures/activities and patient outcomes can be evaluated.

Trauma Center Review
The trauma centers emphasized that a protocol for peer review and reporting of quality of care exemplifies a commitment to quality. Some trauma systems centers indicated that such protocols are already place while others centers had concerns that defining the peer review process may unnecessarily complicate the indicator.


Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study demonstrated good agreement between peer review for preventable deaths and autopsy review93. One study demonstrated that implementation of a trauma quality improvement program that included this quality indicator was associated with reduced hospital mortality45.
Reliability: Eight studies demonstrated good intra-rater and inter-rater reliability for peer review of medical errors and preventable death94,95,96,97,98,99,100,101. One study demonstrated poor agreement between peer-review and TRISS (mortality prediction model)102.
Risk Adjustment: Not applicable.
Utilization: Peer review based measures of quality of injury care are used by a moderate number of trauma centers: USA 20% (40/200), Canada 20% (7/35), Australasia 0% (0/12).


The American College of Surgeons Committee on Trauma has promoted using a multidisciplinary peer review committee to improve care by reviewing sentinel events, complications and deaths2.


2. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient 2006. Chicago: American College of Surgeons; 2006.
45. Chadbunchachai W, Sriwiwat S, Kulleab S, Saranrittichai S, Chumsri J, Jaikwang P. The comparative study for quality of trauma treatment before and after the revision of trauma audit filter, Khon Kaen hospital 1998. J Med Assoc Thai. 2001;84(6):782-790.
93. West JG. Validation of autopsy method for evaluating trauma care. Arch Surg. 1982;117(8):1033-1035.
94. Draaisma JM, de Haan AF, Goris RJ. Preventable trauma deaths in The Netherlands--a prospective multicenter study. J Trauma. 1989;29(11):1552-1557.
95. McDermott FT, Cordner SM, Tremayne AB. Reproducibility of preventable death judgments and problem identification in 60 consecutive road trauma fatalities in Victoria, Australia. Consultative Committee on Road Traffic Fatalities in Victoria. J Trauma. 1997;43(5):831-839.
96. Esposito TJ, Sanddal ND, Hansen JD, Reynolds S. Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. J Trauma. 1995;39(5):955-962.
97. Hill DA, Lennox AF, Neil MJ, Sheehy JP. Evaluation of TRISS as a means of selecting trauma deaths for clinical peer review. Aust N Z J Surg. 1992;62(3):204-208.
98. Demetriades D, Sava J, Alo K, et al. Old age as a criterion for trauma team activation. J Trauma. 2001;51(4):754-756.
99. Kelly AM, Nicholl J, Turner J. Determining the most effective level of TRISS-derived probability of survival for use as an audit filter. Emerg Med (Fremantle). 2002;14(2):146-152.
100. Pories SE, Gamelli RL, Pilcher DB, et al. Practical evaluation of trauma deaths. J Trauma. 1989;29(12):1607-1610.
101. Karmy-Jones R, Copes WS, Champion HR, et al. Results of a multi-institutional outcome assessment: results of a structured peer review of TRISS-designated unexpected outcomes. J Trauma. 1992;32(2):196-203.
102. Fallon WF, Barnoski AL, Mancuso CL, Tinnell CA, Malangoni MA. Benchmarking the quality-monitoring process: a comparison of outcomes analysis by trauma and injury severity score (TRISS) methodology with the peer-review process. J Trauma. 1997;42(5):810-815; discussion 815-817.