557796
research-article2014
FAIXXX10.1177/1071100714557796Foot & Ankle InternationalPinzur
FootForum Foot & Ankle International® 2015, Vol. 36(3) 344 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714557796 fai.sagepub.com
Mortality and Morbidity Michael S. Pinzur, MD1
On a recent Monday morning at Check-Out rounds, the oncall resident presented a seriously injured patient who was admitted to our trauma unit with massive injuries that included a significant pelvic fracture. Over the ensuing 48 hours, the patient succumbed, likely due to massive blood loss. The orthopedic residents involved in the care of this patient voiced concern that the patient did not receive sufficient uncross-matched blood in a timely fashion to address the massive blood loss. The surgical trauma team ultimately chose a different course of resuscitation. In the past, this type of occurrence would have been discussed at both the Orthopaedic Surgery and the General Surgery Mortality and Morbidity Conferences. People in the audience at both conferences would have voiced their opinions. Papers would be quoted. Fingers would have been pointed. At the end of each of the conferences, the only thing that would have been accomplished was a self-serving feeling of arrogance. Nothing would have altered the processes involved in caring for the next severely injured patient with massive blood loss. Everyone involved in the care of this patient was doing the best that they could do. Everyone involved was committed to save the life of the patient. There was simply a disagreement between 2 involved teams as to the best method of treatment. Instead, we chose to review the incident from a more modern process improvement perspective. The first step in the process was a review by a nurse risk manager. The case was profiled and presented to the health system Quality Council. This group of unbiased experienced physicians and nurses not involved in the care of this individual patient carefully reviewed the method of resuscitation. It was learned that our institution has 2 mass transfusion protocols that allow the use of uncross-matched blood. This independent review determined that the method of resuscitation was reasonable, and the eventual outcome would not likely have been altered by using large quantities of uncrossmatched blood. The most valuable lesson learned from the review process was the inefficient method of rapidly obtaining blood, either matched or unmatched, in a critical situation. This led to an audit of the actual time from request to infusion of blood in critically injured patients, which led to
a new procedural pathway for making blood rapidly available in critical situations. In the traditional M&M model of analysis, both involved services would have pointed fingers at the other, blaming the other group for a less than favorable outcome. Hopefully, involved physicians would have learned about the different methods of mass transfusion. Nothing would have addressed the processes that we use every day in caring for patients. The modern QI model of process improvement is based on a nonconfrontational assessment of factual data, combined with an analysis of the processes involved. It turns out that the care that was offered to this patient was perfectly appropriate based on current practice guidelines. Unfortunately, his injury was beyond our ability to resolve his life threatening insult. However, this unfortunate occurrence uncovered a process flaw that delayed blood availability in massive blood loss situations. This nonconfrontational method of analysis allowed us to use our own local objective information to improve our ability to care for the next critically injured patient. Modern quality improvement involves identification of a problem, objective analysis of local available data, interpretation of that data, and, finally, change in process. When done correctly, patient-care benefits. The FootForum appreciates your comments. Please send your comments to [email protected]. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
1
Loyola University Health System, Orthopaedic Surgery, Maywood, IL, USA Corresponding Author: Michael S. Pinzur, MD, Loyola University Health System, Orthopaedic Surgery, 2160 S First Ave, Maywood, IL 60153, USA. Email: [email protected]
Downloaded from fai.sagepub.com at UNIV NEBRASKA LIBRARIES on September 27, 2015
research-article2014
FAIXXX10.1177/1071100714557796Foot & Ankle InternationalPinzur
FootForum Foot & Ankle International® 2015, Vol. 36(3) 344 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714557796 fai.sagepub.com
Mortality and Morbidity Michael S. Pinzur, MD1
On a recent Monday morning at Check-Out rounds, the oncall resident presented a seriously injured patient who was admitted to our trauma unit with massive injuries that included a significant pelvic fracture. Over the ensuing 48 hours, the patient succumbed, likely due to massive blood loss. The orthopedic residents involved in the care of this patient voiced concern that the patient did not receive sufficient uncross-matched blood in a timely fashion to address the massive blood loss. The surgical trauma team ultimately chose a different course of resuscitation. In the past, this type of occurrence would have been discussed at both the Orthopaedic Surgery and the General Surgery Mortality and Morbidity Conferences. People in the audience at both conferences would have voiced their opinions. Papers would be quoted. Fingers would have been pointed. At the end of each of the conferences, the only thing that would have been accomplished was a self-serving feeling of arrogance. Nothing would have altered the processes involved in caring for the next severely injured patient with massive blood loss. Everyone involved in the care of this patient was doing the best that they could do. Everyone involved was committed to save the life of the patient. There was simply a disagreement between 2 involved teams as to the best method of treatment. Instead, we chose to review the incident from a more modern process improvement perspective. The first step in the process was a review by a nurse risk manager. The case was profiled and presented to the health system Quality Council. This group of unbiased experienced physicians and nurses not involved in the care of this individual patient carefully reviewed the method of resuscitation. It was learned that our institution has 2 mass transfusion protocols that allow the use of uncross-matched blood. This independent review determined that the method of resuscitation was reasonable, and the eventual outcome would not likely have been altered by using large quantities of uncrossmatched blood. The most valuable lesson learned from the review process was the inefficient method of rapidly obtaining blood, either matched or unmatched, in a critical situation. This led to an audit of the actual time from request to infusion of blood in critically injured patients, which led to
a new procedural pathway for making blood rapidly available in critical situations. In the traditional M&M model of analysis, both involved services would have pointed fingers at the other, blaming the other group for a less than favorable outcome. Hopefully, involved physicians would have learned about the different methods of mass transfusion. Nothing would have addressed the processes that we use every day in caring for patients. The modern QI model of process improvement is based on a nonconfrontational assessment of factual data, combined with an analysis of the processes involved. It turns out that the care that was offered to this patient was perfectly appropriate based on current practice guidelines. Unfortunately, his injury was beyond our ability to resolve his life threatening insult. However, this unfortunate occurrence uncovered a process flaw that delayed blood availability in massive blood loss situations. This nonconfrontational method of analysis allowed us to use our own local objective information to improve our ability to care for the next critically injured patient. Modern quality improvement involves identification of a problem, objective analysis of local available data, interpretation of that data, and, finally, change in process. When done correctly, patient-care benefits. The FootForum appreciates your comments. Please send your comments to [email protected]. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
1
Loyola University Health System, Orthopaedic Surgery, Maywood, IL, USA Corresponding Author: Michael S. Pinzur, MD, Loyola University Health System, Orthopaedic Surgery, 2160 S First Ave, Maywood, IL 60153, USA. Email: [email protected]
Downloaded from fai.sagepub.com at UNIV NEBRASKA LIBRARIES on September 27, 2015
