Trauma Department Review

Purpose and Overview

The purpose of the interview and consultation was to identify the strengths and weaknesses within the Trauma Department and to develop a plan to address the concern.  An interview was conducted in person with Deborah Krauser, DNP, APRN, ANP-BC, CEN.  Deborah is the Trauma Program Manager at Texas Health Fort Worth, a busy Level II Trauma Center in Fort Worth, Texas.  An overview of current policies, procedures, processes and benchmark data was reviewed.  Based upon the interview, it was recommended that interventions are needed to ensure that the best practice guidelines set by the American College of Surgeons with regards to Alcohol Screening and Brief Intervention for Trauma Patient (SBIRT) be completed on every admitted trauma patient.  According to trauma registry data provided by Deborah, currently 95% of admitted trauma patients at the facility are being screening for alcohol use, but only 85% of those identified, are receiving brief interventions.  A plan will be provided through the consultation process that will include:  results of evaluation, education for staff, interventions to improve benchmark outcomes, and evaluation of intervention.  The goal of this intervention will be to increase best standard guideline of SBIRT to 100% on all trauma patients.

Description of Organization

 Texas Health Resources is one of the largest faith-based non-profit organizations in the United States with 29 hospital locations, 100 plus outpatient facilities, 250 primary care offices and over 24,000 employees.  Texas Health Fort Worth is a 720 bed facility that serves 23 counties with in the Fort Worth Area (Our Organization – Texas Health Resources, 2018).  Texas Helath Fort Worth is a Level II Trauma facility accredited by the American College of Surgeons, with a 100 bed emergency room that has 22 emergent care rooms and 4 trauma resusitaion rooms (Why Choose Texas Health Fort Worth?, 2018).  In 2017 Texas Health Fort Worth treated 21, 634 injured patients in the emergency patients with 3,354 being admited to trauma services (Texas Health Resources, 2018)

Texas Health Fort Worth has earned many distinguished honors and certifications:

• Magnet designated hospital (three times).
• Designated Level II Trauma Center by the American College of Surgeons.
• Joint Commission certified in Heart Failure, Chest Pain, Palliative Care, and Hip and Knee Replacement.
• Comprehensive Stroke Center and Comprehensive Community Cancer Center.
• The Joint Commission’s Gold Seal of Approval for Brain Tumor Certification.
• Only designated Lung Cancer Screening Center in Fort Worth recognized by the American College of Radiology.

(Certifications and Honors, 2018) 

 Texas Health’s organizational structure is complex for a large organization and is divided into zones that report to the Chief Executive officer. 

(Texas Health Leadership, 2018) 

 Each Hospital is ran by the President, Chief Nursing Officer and Chief Medical Officer that report to the zone leaders.  Staff nurses report to unit managers who oversee that the staff on that particular unit.  Nurse Managers report to a Nurse Director, who then reports to the CNO.

Primary Needs of Population

Texas Health Fort Worth is located in Tarrant County with a population of 2,054,475.  The population breakdown is as follows:

(U.S. Census Bureau QuickFacts: Tarrant County, Texas., 2017) 

 A Community Needs Assessment was completed in 2016 by Texas Health Fort Worth with implementation strategies to be carried out from 2107-2019.  The major community health and wellness needs identified were:  mental health and substance abuse, exercise, nutrition and weight, and access to health services and healthcare navigation.  Mental health and substance abuse play a key role in many admitted injured trauma patients.  The ability to identify substance abuse early in admission can help with complications and length of stay.  Per the American College of Surgeons, when a trauma patient is screened for alcohol abuse and interventions are received, there is a 50% reduction in recidivism (Alcohol Screening and Brief Intervention, 2015).

Nurse Leader Role

The nurse leader interviewed was Deborah Krauser the Trauma Program Manager.  Deborah has her Doctor in Nursing Practice.  The Trauma Program Manager (TPM) is responsible for maintaining Trauma Designation through the American College of Surgeons.  This includes providing a comprehensive quality assessment on all injured patients. The TPM oversees a variety of different job descriptions such as:  Trauma Registrar, Injury Prevention Coordinator, Process Improvement Coordinator, Trauma Research Coordinator, Trauma Clinician, and Administrative Assistant. The TPM reports directly to the Director of Restorative Services. 

Deborah outlined the Trauma Program Manager’s responsibilities to include, but not limited to:   

• Coordinate with the medical director, hospital administration to evaluate and review policies, procedures and protocols relating to the care of trauma patients.
• Develop policies and procedures based on best practice guidelines.
• Represent the Trauma Program on various hospital and community committees to enhance and foster optimal trauma care management.  
• Monitor and maintain compliance with statewide trauma system regulatory requirements.
• Participate in state and regional trauma care activities.
• Monitor national and statewide trends in trauma care.
• Coordinate with physicians, nurses, and other hospital staff to evaluate and address specific patient care issues.
• Serve as the coordinator for the identification, investigation, reporting and follow up of incidents and quality improvement issues throughout the program while maintaining patient confidentiality.
• Manage registry data: collect, analyze and trend.
• Develop and monitor the trauma Process Improvement program in collaboration with the trauma program medical director.
• Plan, coordinate and evaluate trauma-related educational programs for nursing staff and community.

 Deborah serves as the primary contact for anything related to the trauma patient for clinical units.  The TPM actively partners with nursing leaders within the facility as well as other entities to improve trauma patient care using evidenced based strategies.  The Essentials in Master’s Nursing that Deborah exhibits are:

• Essential II: Organizational and Systems Leadership – demonstrated by unifying her own team, but also developing and improving trauma relationships throughout the system. 
• Essential III: Quality Improvement and Safety – demonstrated by performing QI on all injured trauma patients and critically reviewing deaths to improve patient care.
• Essential V: Informatics and Healthcare Technologies – demonstrated by using data to guide practice and to drive change. 
• Essential VI: Health Policy and Advocacy – demonstrated by actively serving on committees at both the local and state level to better trauma informed care.
• Essential VII: Interprofessional Collaboration for Improving Patient and Population Health Outcomes – demonstrated by implementing walking multidisciplinary rounds on all critically ill trauma patients in the ICU. 
• Essential VIII: Clinical Prevention and Population Health for Improving Health – demonstrated by community outreach to educate public about trauma specific injuries and prevention of these injuries.
• Essential IV: Translating and Integrating Scholarship into Practice – demonstrated by participating in national research studies to further improved trauma patient outcomes, while maintaining patient confidentiality.

(American Association of Colleges of Nursing, 2011)

Characteristics of Organization

A strength of Texas Health Fort Worth, is that the trauma program values providing excellent care to patients.  This is done by maintaining policies and procedures based on evidence based guidelines.  Texas Health Fort Worth reviews all of the policies and procedures for trauma every two years, or if there is an evidence based change that needs to be implemented.  This review process allows for the most up to date care to be given.  Another strength of Texas Health Fort Worth is the amount of education that is provided to all the health care providers that care for trauma patients.  There are monthly multidisciplinary education sessions, as well as unit specific education that is identified though process improvement. 

A weakness identified for Texas Health Fort Worth is the constancy in which evidence based guidelines are upheld and maintained outside of the trauma units.  Many trauma patients are being cared for on non-typical trauma units due to hospital census.  For example the orthopedics step down unit often takes care of trauma overflow patients, although many trauma patients do have orthopedic injuries, this unit primarily cares for post-op hip fracture patients. The staff on the overflow units have not been formally trained in the requirements stated by the American College of Surgeons with regards to Alcohol Screening and Brief Interventions. Another identified weakness is at the system level, within the system there are hospitals with different trauma verification levels and the system is trying to streamline policies and procedures across the system for trauma,  Unfortunately, the standards per the American College of Surgeons is different depending on the trauma verification level, therefore, requiring different procedures for different levels. 

Process improvement is Deborah’s main “job” being the Trauma Program Manager.  All complications, guideline deviations and deaths are critically reviewed for any process that could be improved for better care of the trauma patient.  These items identified are reviewed with the Process Improvement Committee.  During the bi-monthly committee meetings, care of the trauma patient is discussed to see where improvements could have been made and if there is a need for any change in processes or procedures to prevent this from happening again. 

Recommendation for Organizational Change

It is recommended ER staff, ICU (Neruo, Med-Surg and Cardiac) staff, and orthopedic step down unit staff members be educated on the Alcohol Screening and Brief Intervention for Trauma Patient (SBIRT). 

Rationale for Recommended Change

The education on SBIRT will have a twofold impact on patient care: 1. Help meet the needs identified in the Community Needs Assessment at a Hospital Level of mental health and substance abuse and access to healthcare services and 2.  Meet the requirement of the American College of Surgeons that all trauma patients must be screened and receive a brief intervention.  SBIRT is a community health approach to identifying those at risk for substance disorders through screening.  If a screening identifies need for further assessment, a brief intervention can be easily provided by the healthcare provider.  The brief intervention includes information or referral to services to help improve access to care.  Alcohol screening and brief intervention have been proven to reduce recidivism by 50% for those who have been arrested for driving while under the influence (Alcohol Screening and Brief Intervention, 2015). 

Measures to Evaluate

 Measures to evaluate effectiveness of education is through an internal scorecard.  Certain metrics are input into the trauma data registry for all trauma patients.  The data can then be pulled on a monthly basis to see if Alcohol screening and interventions have been performed.  Data from the scorecard can be compared pre and post education to evaluate effectiveness of education process.  This data can also be drilled down to specific units and healthcare providers, allowing for further re-education if needed.

 Community Health Needs Assessment must be done every three years as mandated by the federal government (Community Health Needs Assessment, 2017).  Hospitals are required to formulate plans and reassess to identify is measures have been met. Another way to evaluate is measure has been met, would be through this re-assessment.  If the metric has decreased or is no longer on the needs list, the recommended change was successful.  

References

• American Association of Colleges of Nursing. (2011).  The essentials of mater’s education in nursing. Retrieved from: https://www.aacn.nche.edu/education-resources-MasterEssentials11.pdf
• Alcohol Screening and Brief Intervention. (2015). Retrieved from American College of Surgeons: https://www.facs.org/~/media/files/quality%20programs/trauma/publications/sbirtguide.ashx
• Certifications and Honors. (2018). Retrieved from Texas Health Resources: https://www.texashealth.org/fortworth/about-texas-health-fort-worth/certifications-and-honors
• Community Health Needs Assessment. (2017). Retrieved from Texas Health Resources: https://www.texashealth.org/community-engagement/community-health-improvement-chi/community-health-needs-assessment
• Our Organization – Texas Health Resources. (2018, February). Retrieved from Texas Health Resources:  http://responsibility.texashealth.org/chapters/our-organization/
• Texas Health Leadership. (2018, September). Retrieved from Texas Health Resources: https://www.texashealth.org/fortworth/about-texas-health-fort-worth/leadership
• Texas Health Resources. (2018, February). Texas Health Fort Worth: Trauma Annual Report 2017. Fort Worth.
• U.S. Census Bureau QuickFacts: Tarrant County, Texas. (2017, July). Retrieved from https://www.census.gov/quickfacts/fact/table/tarrantcountytexas/PST045217
• Why Choose Texas Health Fort Worth? (2018). Retrieved from Texas Health Resources: https://www.texashealth.org/fortworth/services/emergency-department/why-choose-texas-health-fort-worth/#trauma