Background:The evaluation of trauma center performance implies the use of indicators that evaluate clinical processes. Despite the availability of routinely collected clinical data in most trauma systems, quality improvement efforts are often limited to hospital-based audit of adverse patient outcomes.Objective:To identify and evaluate a series of process performance indicators (PPI) that can be calculated using routinely collected trauma registry data.Materials and Methods:PPI were identified using a review of published literature, trauma system documentation, and expert consensus. Data from the 59 trauma centers of the Quebec trauma system (1999, 2006; N = 99,444) were used to calculate estimates of conformity to each PPI for each trauma center. Outliers were identified by comparing each center to the global mean. PPI were evaluated in terms of discrimination (between-center variance), construct validity (correlation with designation level and patient volume), and forecasting (correlation over time).Results:Fifteen PPI were retained. Global proportions of conformity ranged between 6% for reduction of a major dislocation within 1 h and 97% for therapeutic laparotomy. Between-center variance was statistically significant for 13 PPI. Five PPI were significantly associated with designation level, 7 were associated with volume, and 11 were correlated over time.Conclusion:In our trauma system, results suggest that a series of 15 PPI supported by literature review or expert opinion can be calculated using routinely collected trauma registry data. We have provided evidence of their discrimination, construct validity, and forecasting properties. The between-center variance observed in this study highlights the importance of evaluating process performance in integrated trauma systems.

for the Low-Value Practices in Trauma Care Expert Consensus Group IMPORTANCE The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. OBJECTIVE To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care.DESIGN, SETTING, AND PARTICIPANTS This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. MAIN OUTCOMES AND MEASURESPanelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. RESULTSOf 49 eligible experts approached, 46 (94%; 18 experts [39%] aged Ն50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), ( 4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and ( 9) routine blood work (minor orthopedic surgery). CONCLUSIONS AND RELEVANCEIn this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.

Patients with HIP represented 21.1% of admissions while accounting for 42% of total days of hospitalization and 38% of deaths. Patients with hip fractures have a significantly higher risk of death, prolonged hospital stay, and complication rate, and are more often transferred to a rehabilitation center or to a long-term nursing home than the rest of the trauma population despite lower severity. They require multidisciplinary care typical of the rest of the trauma population and should be included in the trauma registry if the registry is to document the full outcome and resource use of the trauma population.

ImportanceReducing low-value care has the potential to improve patient experiences and outcomes and free up health care resources. Sixteen quality indicators were recently developed targeting reductions in low-value trauma care based on a synthesis of the best available evidence, expert consensus, and patient preferences.ObjectiveTo assess the validity of quality indicators on low-value trauma care using trauma registry data.Design, Setting, and ParticipantsData from an inclusive Canadian provincial trauma system were used in this analysis. Included were all admissions for injury to any of the 57 provincial adult trauma centers between April 1, 2013, and March 31, 2020. Metrics for quality indicators were developed iteratively with clinical experts.Main Outcomes and MeasuresValidity was assessed using a priori criteria based on 5 parameters: frequency (incidence and case volume), discrimination (interhospital variation), construct validity (correlation with quality indicators on high-value care), predictive validity (correlation with quality indicators on risk-adjusted outcomes), and forecasting (correlation over time).ResultsThe study sample included 136 783 patient admissions (mean [SD] age, 63 [22] years; 68 428 men [50%]). Metrics were developed for 12 of the 16 quality indicators. Six quality indicators showed moderate or high validity on all measurable parameters: initial head, cervical spine, or whole-body computed tomography for low-risk patients; posttransfer repeated computed tomography; neurosurgical consultation for mild complicated traumatic brain injury; and spine service consultation for isolated thoracolumbar process fractures. Red blood cell transfusion in low-risk patients had low frequency but had moderate or high validity on all other parameters. Five quality indicators had low validity on at least 2 parameters: repeated head CT and intensive care unit admission for mild complicated traumatic brain injury, hospital admission for minor blunt abdominal trauma, orthosis for thoracolumbar burst fractures, and surgical exploration in penetrating neck injury without hard signs.Conclusions and RelevanceThis cohort study shows the feasibility of assessing low-value trauma care using routinely collected data. It provided data on quality indicators properties that can be used to decide which quality indicators are most appropriate in a given system. Results suggest that 6 quality indicators have moderate to high validity. Their implementation now needs to be tested.

The incidence of blunt thoracic and abdominal injuries needing surgical intervention is low in Quebec tertiary trauma centers. The competence of general surgeons in trauma-related procedures might be compromised by such low patient volume unless they frequently perform non-trauma surgical procedures. We think that in Quebec, trauma care must be provided by surgeons who practice both acute emergency and elective surgical care in addition to trauma care. These findings should have an important impact on the development of on-going education and resident training programs.