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Figure 1. Selection of articles for review. QI indicates quality indicator.

Figure 1. Selection of articles for review. QI indicates quality indicator.

Figure 2. Distribution of published quality indicators (QIs) in trauma care.

Figure 2. Distribution of published quality indicators (QIs) in trauma care.

Table 1. 
Quality Indicator Classification Schemea
Quality Indicator Classification Schemea
Table 2. 
Characteristics of Articles on Quality Indicators (QIs) in Trauma Care
Characteristics of Articles on Quality Indicators (QIs) in Trauma Care
Table 3. 
Characteristics of Quality Indicators (QIs) in Trauma Care
Characteristics of Quality Indicators (QIs) in Trauma Care
Table 4. 
Categorization of Quality Indicators (QIs) in Trauma Care
Categorization of Quality Indicators (QIs) in Trauma Care
Table 5. 
Author Recommendations for Quality Indicators (QIs) in Trauma Care
Author Recommendations for Quality Indicators (QIs) in Trauma Care
Table 6. 
Candidate Quality Indicators (QIs) for Systematic Review
Candidate Quality Indicators (QIs) for Systematic Review
1.
Murray  CJLopez  AD Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 1997;349 (9061) 1269- 1276
PubMedArticle
2.
Bergen  GChen  LHWarner  MFingerhut  LA Injury in the United States: 2007 Chartbook.  Hyattsville, MD: National Center for Health Statistics; 2008
3.
Miller  TRPindus  NMDouglass  JBRossman  SB Databook on Nonfatal Injury: Incidence, Costs and Consequences.  Washington, DC: Urban Institute Press; 1995
4.
Rice  DPMacKenzie  EJ The Cost of Injury in the United States: A Report to Congress.  San Francisco, CA: Institute for Health and Aging, University of California and the Injury Prevention Center, Johns Hopkins University; 1989
5.
Institute of Medicine Committee on the Quality of Health Care in America Crossing the Quality Chasm: A New Health System for the 21st Century.  Washington, DC: National Academy Press; 2001
6.
Institute of Medicine To Err Is Human.  Washington, DC: National Academy Press; 1999
7.
Rhodes  MSacco  WSmith  SBoorse  D Cost effectiveness of trauma quality assurance audit filters. J Trauma 1990;30 (6) 724- 727
PubMedArticle
8.
Nayduch  DMoylan  JSnyder  BLAndrews  LRutledge  RCunningham  P American College of Surgeons trauma quality indicators: an analysis of outcome in a statewide trauma registry. J Trauma 1994;37 (4) 565- 575
PubMedArticle
9.
Copes  WSStaz  CFKonvolinka  CWSacco  WJ American College of Surgeons audit filters: associations with patient outcome and resource utilization. J Trauma 1995;38 (3) 432- 438
PubMedArticle
10.
Cryer  HGHiatt  JRFleming  AWGruen  JPSterling  J Continuous use of standard process audit filters has limited value in an established trauma system. J Trauma 1996;41 (3) 389- 395
PubMedArticle
11.
O’Keefe  GEJurkovich  GJMaier  RV Defining excess resource utilization and identifying associated factors for trauma victims. J Trauma 1999;46 (3) 473- 478
PubMedArticle
12.
Hoyt  DBHollingsworth-Fridlund  PFortlage  DDavis  JWMackersie  RC An evaluation of provider-related and disease-related morbidity in a level I university trauma service: directions for quality improvement. J Trauma 1992;33 (4) 586- 601
PubMedArticle
13.
Davis  JWHoyt  DB McArdle  MSMackersie  RCShackford  SREastman  AB The significance of critical care errors in causing preventable death in trauma patients in a trauma system. J Trauma 1991;31 (6) 813- 819
PubMedArticle
14.
Trunkey  DLewis  F Preventing mortality.  In: Trunkey  D, Lewis  F, eds. Current Therapy of Trauma.3rd ed. Philadelphia, PA: Decker; 1991:3-4
15.
Mendeloff  JMCayten  CG Trauma systems and public policy. Annu Rev Public Health 1991;12401- 424
PubMedArticle
16.
West  JGTrunkey  DDLim  RC Systems of trauma care: a study of two counties. Arch Surg 1979;114 (4) 455- 460
PubMedArticle
17.
MacKenzie  EJSteinwachs  DMBone  LRFloccare  DJRamzy  AI Inter-rater reliability of preventable death judgments: the Preventable Death Study Group. J Trauma 1992;33 (2) 292- 303
PubMedArticle
18.
Shackford  SRHollingsworth-Fridlund  P McArdle  MEastman  AB Assuring quality in a trauma system—the Medical Audit Committee: composition, cost, and results. J Trauma 1987;27 (8) 866- 875
PubMedArticle
19.
Teixeira  PGInaba  KHadjizacharia  P  et al.  Preventable or potentially preventable mortality at a mature trauma center. J Trauma 2007;63 (6) 1338- 1346
PubMedArticle
20.
Agency for Healthcare Research and Quality AHRQ Quality Indicators Web site. http://www.qualityindicators.ahrq.gov/. Accessed January 6, 2009
21.
Canadian Institute for Health Information 2004 National Trauma Registry Injury Hospitalizations Report. http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR8_2002sum_e. Accessed January 6, 2009
22.
Mitchell  FLThal  ERWolferth  CC Analysis of American College of Surgeons trauma consultation program. Arch Surg 1995;130 (6) 578- 583
PubMedArticle
23.
Baker  SPO’Neill  BHaddon  W  JrLong  WB The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14 (3) 187- 196
PubMedArticle
24.
Bergeron  ELavoie  ABelcaid  ARatte  SClas  D Should patients with isolated hip fractures be included in trauma registries? J Trauma 2005;58 (4) 793- 797
PubMedArticle
25.
Berlin  JA Does blinding of readers affect the results of meta-analyses? University of Pennsylvania Meta-analysis Blinding Study Group. Lancet 1997;350 (9072) 185- 186
PubMedArticle
26.
McGlynn  EA Selecting common measures of quality and system performance. Med Care 2003;41 (1) (suppl)I39- I47
PubMed
27.
Wilberger  JE  JrHarris  MDiamond  DL Acute subdural hematoma: morbidity and mortality related to timing of operative intervention. J Trauma 1990;30 (6) 733- 736
PubMedArticle
28.
Donabedian  A The Definition of Quality and Approaches to Its Assessment.  Ann Arbor, MI: Health Administration Press; 1980
29.
Donabedian  A Evaluating the quality of medical care. Milbank Q 2005;83 (4) 691- 729
PubMedArticle
30.
 Hospital resources for optimal care of the injured patient: prepared by a task force of the Committee on Trauma of the American College of Surgeons. Bull Am Coll Surg 1979;64 (8) 43- 48
PubMed
31.
 Preliminary analysis of the care of injured patients in five Scottish teaching hospitals: first report from the Scottish Trauma Audit Group (STAG). Health Bull (Edinb) 1995;53 (1) 55- 65
PubMed
32.
 Trauma program bolsters case for better equipment with benchmarking study. Healthc Benchmarks 2001;8 (2) 13- 16
PubMed
33.
 Prehospital evidence-based clinical performance measures published. EMS Insider 2008;351- 6
34.
Al-Naami  MYAl-Faki  AASadik  AA Quality improvement data analysis of a mass casualty event. Injury 2003;34 (11) 857- 861
PubMedArticle
35.
Alvarez  JRRodriguez  JASanchez  CCMalpica  ABRomero  FR Hospital trauma death: results of multidisciplinary audit in 43 trauma deaths in ICU [in Spanish]. Med Intensiva 1995;19454- 461
36.
American College of Emergency Physicians, Trauma care systems quality improvement guidelines. Ann Emerg Med 1992;21 (6) 736- 739
PubMedArticle
37.
Anderson  IDWoodford  Mde Dombal  FTIrving  M Retrospective study of 1000 deaths from injury in England and Wales. Br Med J (Clin Res Ed) 1988;296 (6632) 1305- 1308
PubMedArticle
38.
Bailey  MMForrester  CB Trauma quality assurance: peer review forum. J Emerg Nurs 1989;1522A- 24A
PubMed
39.
Barendregt  WBde Boer  HHKubat  K Quality control in fatally injured patients: the value of the necropsy. Eur J Surg 1993;159 (1) 9- 13
PubMed
40.
Berroeta  FOdriozola  FAGarde  PM  et al.  Clinical and autopsy evaluation of quality of care of severely ill trauma patients in the Guipuzcoa Province [in Spanish]. Med Intensiva 1999;23100- 110
41.
Blank-Reid  CAKaplan  LJ Video recording trauma resuscitations: a guide to system set-up, personnel concerns, and legal issues. J Trauma Nurs 1996;3 (1) 9- 12
PubMed
42.
Boonmak  PThanapaisal  CTecha-atik  PKanya  WSuntaraporn  W Trauma care audit using Srinagarind hospital's audit filter. J Med Assoc Thai 2008;91 (11) 1714- 1718
PubMed
43.
Bouamra  OWrotchford  AHollis  SVail  AWoodford  MLecky  F Outcome prediction in trauma. Injury 2006;37 (12) 1092- 1097
PubMedArticle
44.
Bouillon  BKramer  MPaffrath  TDimmeler  SNeugebauer  ETiling  T Quality assurance in the management of severely ill patients: how can score systems help? [in German]. Unfallchirurg 1994;97 (4) 191- 198
PubMed
45.
Bouillon  BNeugebauer  E Quality management of severely injured patients [in German]. Z Arztl Fortbild Qualitatssich 2001;95 (7) 475- 478
PubMed
46.
Braunling-McMorrow  DEvans  R A quality scorecard for community-based services. Brain Inj Professional. 24-27.http://thementornetwork.com/documents/pdf/12_ScoreCardArticleBIP.pdf. Accessed April 28, 2009
47.
Bull  JP Trauma audit. Arch Emerg Med 1989;6 (4) 288- 289
PubMed
48.
Cales  RHTrunkey  DD Preventable trauma deaths: a review of trauma care systems development. JAMA 1985;254 (8) 1059- 1063
PubMedArticle
49.
Cayten  CGStahl  WMAgarwal  NMurphy  JG Analyses of preventable deaths by mechanism of injury among 13,500 trauma admissions. Ann Surg 1991;214 (4) 510- 521
PubMedArticle
50.
Chadbunchachai  WSaranrittichai  SSriwiwat  SChumsri  JKulleab  SJaikwang  P Study on performance following Key Performance Indicators for trauma care: Khon Kaen Hospital 2000. J Med Assoc Thai 2003;86 (1) 1- 7
PubMed
51.
Chadbunchachai  WSriwiwat  SKulleab  SSaranrittichai  SChumsri  JJaikwang  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
PubMed
52.
Champion  HRCopes  WSSacco  WJ  et al.  The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma 1990;30 (11) 1356- 1365
PubMedArticle
53.
Chang  DCHandly  NAbdullah  F  et al.  The occurrence of potential patient safety events among trauma patients: are they random? Ann Surg 2008;247 (2) 327- 334
PubMedArticle
54.
Chesnut  RM Should we be using evidence-based quality assurance benchmarks to choose brain injury management centers? Crit Care Med 2002;30 (8) 1927- 1929
PubMedArticle
55.
Clark  DECushing  BMBredenberg  CE Monitoring hospital trauma mortality using statistical process control methods. J Am Coll Surg 1998;186 (6) 630- 635
PubMedArticle
56.
Cocanour  CSPeninger  MDomonoske  BD  et al.  Decreasing ventilator-associated pneumonia in a trauma ICU. J Trauma 2006;61 (1) 122- 130
PubMedArticle
57.
Collopy  BTBalding  C The Australian development of national quality indicators in health care. Jt Comm J Qual Improv 1993;19 (11) 510- 516
PubMed
58.
Cooper  AHannan  ELBessey  PQFarrell  LSCayten  CGMottley  L An examination of the volume-mortality relationship for New York State trauma centers. J Trauma 2000;48 (1) 16- 23
PubMedArticle
59.
Copes  WSSacco  WJChampion  HR Evaluations of hospital and/or trauma care systems. Arch Emerg Med 1989;6 (3) 165- 168
PubMed
60.
Coastal Valleys EMS Agency Trauma Care System. http://www.sonoma-county.org/cvrems/resources/pdf/policy/sysorg24_trauma.pdf. Accessed April 28, 2009
61.
Davies  S Trauma scoring. Accid Emerg Nurs 1993;1 (3) 125- 131Article
62.
Davis  JWHoyt  DB McArdle  MS  et al.  An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement. J Trauma 1992;32 (5) 660- 666
PubMedArticle
63.
Demetriades  DChan  LSVelmahos  G  et al.  TRISS methodology in trauma: the need for alternatives. Br J Surg 1998;85 (3) 379- 384
PubMedArticle
64.
Demetriades  DMartin  MSalim  ARhee  PBrown  CChan  L The effect of trauma center designation and trauma volume on outcome in specific severe injuries. Ann Surg 2005;242 (4) 512- 519
PubMed
65.
Di Bartolomeo  SValent  FRosolen  V  et al.  Are pre-hospital time and emergency department disposition time useful process indicators for trauma care in Italy? Injury 2007;38 (3) 305- 311
PubMedArticle
66.
Di Bartolomeo  SValent  FSanson  GNardi  GGambale  GBarbone  F Are the ACSCOT filters associated with outcome? examining morbidity and mortality in a European setting. Injury 2008;39 (9) 1001- 1006
PubMedArticle
67.
Dowd  MD Effect of emergency department care on outcomes in pediatric trauma: what approaches make a difference in quality of care? J Trauma 2007;63 (6) (suppl)S136- S139
PubMedArticle
68.
Draaisma  JMde Haan  AFGoris  RJ Preventable trauma deaths in the Netherlands: a prospective multicenter study. J Trauma 1989;29 (11) 1552- 1557
PubMedArticle
69.
Dykes  EHSpence  LJYoung  JGBohn  DJFiller  RMWesson  DE Preventable pediatric trauma deaths in a metropolitan region. J Pediatr Surg 1989;24 (1) 107- 111
PubMedArticle
70.
Eastes  LHarrahill  M The Trauma Audit Group (TAG): Oregon's 13-year experience. J Emerg Nurs 2002;28 (4) 365- 366
PubMedArticle
71.
Eckstein  MAlo  K The effect of a quality improvement program on paramedic on-scene times for patients with penetrating trauma. Acad Emerg Med 1999;6 (3) 191- 195
PubMedArticle
72.
Ehlinger  KGardner  MJNakayama  DK The trauma registry: an administrative and clinical tool. Top Health Rec Manage 1990;11 (2) 43- 48
PubMed
73.
Ehrlich  PF McClellan  WTWesson  DE Monitoring performance: longterm impact of trauma verification and review. J Am Coll Surg 2005;200 (2) 166- 172
PubMedArticle
74.
Ehrlich  PFRockwell  SKincaid  SMucha  P  Jr American College of Surgeons, Committee on Trauma Verification Review: does it really make a difference? J Trauma 2002;53 (5) 811- 816
PubMedArticle
75.
El-Masri  MM McLeskey  SWKorniewicz  DM Nosocomial bloodstream infection surveillance in trauma centers: the lack of uniform standards. Am J Infect Control 2004;32 (6) 370- 371
PubMedArticle
76.
Esposito  TJSanddal  NDHansen  JDReynolds  S Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. J Trauma 1995;39 (5) 955- 962
PubMedArticle
77.
Fallon  WF  JrBarnoski  ALMancuso  CLTinnell  CAMalangoni  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- 817
PubMedArticle
78.
Flex Monitoring Team Rural hospital emergency department quality measures: aggregate data report. http://www.flexmonitoring.org/documents/FlexDataSummaryReport3.pdf. Accessed April 30, 2009
79.
Forsythe  RMLivingston  DHLavery  RFMosenthal  ACHauser  CJ Autopsies in trauma do not add to peer review or quality assurance. J Trauma 2002;53 (2) 321- 325
PubMedArticle
80.
Gallagher  C Applying quality improvement tools to quality planning: pediatric femur fracture clinical path development. J Healthc Qual 1994;16 (3) 6- 14
PubMedArticle
81.
Gentilello  LM Alcohol and injury: American College of Surgeons Committee on Trauma requirements for trauma center intervention. J Trauma 2007;62 (6) (suppl)S44- S45
PubMedArticle
82.
Giles  SJCook  GAJones  MA  et al.  Evaluating the effectiveness of multi-professionally agreed list of adverse events for clinical incident reporting in trauma and orthopedics: a follow-up study. Clin Governance Int J 2005;10217- 230Article
83.
Glance  LGDick  AOsler  TMMukamel  D Judging trauma center quality: does it depend on the choice of outcomes? J Trauma 2004;56 (1) 165- 172
PubMedArticle
84.
Glance  LGOsler  TMDick  AW Evaluating trauma center quality: does the choice of the severity-adjustment model make a difference? J Trauma 2005;58 (6) 1265- 1271
PubMedArticle
85.
Gore  DCHawkins  HKChinkes  DL  et al.  Assessment of adverse events in the demise of pediatric burn patients. J Trauma 2007;63 (4) 814- 818
PubMedArticle
86.
Gorman  DFTeanby  DNSinha  MPWotherspoon  JBoot  DAMolokhia  A Preventable deaths among major trauma patients in Mersey Region, North Wales and the Isle of Man. Injury 1996;27 (3) 189- 192
PubMedArticle
87.
Gruen  RLJurkovich  GJ McIntyre  LKFoy  HMMaier  RV Patterns of errors contributing to trauma mortality: lessons learned from 2594 deaths. Ann Surg 2006;244 (3) 371- 380
PubMed
88.
Guenther  SWaydhas  COse  CNast-Kolb  DMultiple Trauma Task Force, German Trauma Society, Quality of multiple trauma care in 33 German and Swiss trauma centers during a 5-year period: regular versus on-call service. J Trauma 2003;54 (5) 973- 978
PubMedArticle
89.
Hammond  JEckes  JWelcom  A Improved compliance with quality assurance markers during trauma room resuscitation using trauma nurse specialists. Am J Emerg Med 1992;10 (4) 323- 325
PubMedArticle
90.
Harris  DP Outcome measure and program evaluation model for post acute brain injury rehabilitation. J Rehab Outcome Measure.1997;1:23-30
91.
Haut  ERNoll  KEfron  DT  et al.  Can increased incidence of deep vein thrombosis (DVT) be used as a marker of quality of care in the absence of standardized screening? the potential effect of surveillance bias on reported DVT rates after trauma. J Trauma 2007;63 (5) 1132- 1137
PubMedArticle
92.
Helvig  EIUpright  JBartleson  BJ The development of outcome statements for burn care. Semin Perioper Nurs 1997;6 (4) 197- 200
PubMed
93.
Henderson  KICoats  TJHassan  TBBrohi  K Audit of time to emergency trauma laparotomy. Br J Surg 2000;87 (4) 472- 476
PubMedArticle
94.
Hill  DALennox  AFNeil  MJSheehy  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
PubMedArticle
95.
Hirshberg  AThomson  SRBade  PGHuizinga  WK Pitfalls in the management of penetrating chest trauma. Am J Surg 1989;157 (4) 372- 376
PubMedArticle
96.
Hodgetts  TJDavies  SRussell  R McLeod  J Benchmarking the UK military deployed trauma system. J R Army Med Corps 2007;153 (4) 237- 238
PubMed
97.
Hollingsworth-Fridlund  PMattice  CHotz  HMartin  KFitzpatrick  KKlein  J A trauma performance improvement template. J Trauma Nurs 2004;11 (4) 144- 152
98.
Hoyt  DBCoimbra  R Trauma systems. Surg Clin North Am 2007;87 (1) 21- 35
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101.
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102.
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PubMedArticle
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Kelly  AMEpstein  J Preventable death studies: an inappropriate tool for evaluating trauma systems. Aust N Z J Surg 1997;67 (9) 591- 592
PubMedArticle
105.
Kelly  AMNicholl  JTurner  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
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106.
Kidner  NLWardrope  L Trauma audit. Care Critically Ill.1993;9:241-245
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Kissoon  NTepas  JJ  IIIPeterson  RJPieper  PGayle  MO The evaluation of pediatric trauma care using audit filters. Pediatr Emerg Care 1996;12 (4) 272- 276
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108.
Klein  CJHenry  SM Acute nutrition interventions help identify indicators of quality in a trauma service. Nutr Clin Pract 1999;14 (2) 85- 92Article
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PubMedArticle
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McDermott  FT Trauma audit and quality improvement. Aust N Z J Surg 1994;64 (3) 147- 154
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McDermott  FTCordner  SMCooper  DJWinship  VCConsultative Committee on Road Traffic Fatalities in Victoria, Management deficiencies and death preventability of road traffic fatalities before and after a new trauma care system in Victoria, Australia. J Trauma 2007;63 (2) 331- 338
PubMedArticle
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PubMedArticle
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McDermott  FTCordner  SMTremayne  ABConsultative Committee on Road Traffic Fatalities in Victoria, Management deficiencies and death preventability in 120 Victorian road fatalities (1993-1994). Aust N Z J Surg 1997;67 (9) 611- 618
PubMedArticle
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McDermott  FTCordner  SMTremayne  AB Reproducibility of preventable death judgments and problem identification in 60 consecutive road trauma fatalities in Victoria, Australia. J Trauma 1997;43 (5) 831- 839
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PubMedArticle
123.
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PubMed
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PubMedArticle
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Miller  PRJohnson  JC  IIIKarchmer  THoth  JJMeredith  JWChang  MC National nosocomial infection surveillance system: from benchmark to bedside in trauma patients. J Trauma 2006;60 (1) 98- 103
PubMedArticle
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PubMedArticle
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Myers  JBSlovis  CMEckstein  M  et al. US Metropolitan Municipalities' EMS Medical Directors, Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care 2008;12 (2) 141- 151
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Review
March 2010

Quality Indicators for Evaluating Trauma CareA Scoping Review

Author Affiliations

Author Affiliations: Departments of Critical Care Medicine (Drs Stelfox and Bobranska-Artiuch), Medicine, and Community Health Sciences (Dr Stelfox), University of Calgary, Calgary, Alberta; and Division of Trauma, Departments of Surgery (Dr Nathens) and Medicine (Dr Straus), Saint Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.

Arch Surg. 2010;145(3):286-295. doi:10.1001/archsurg.2009.289
Abstract

Objectives  To systematically review the literature on quality indicators (QIs) for evaluating trauma care, identify QIs, map their definitions, and examine the evidence base in support of the QIs.

Data Sources  We searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials from the earliest available date through January 14, 2009. To increase the sensitivity of the search, we also searched the grey literature and select journals by hand, reviewed reference lists to identify additional studies, and contacted experts in the field.

Study Selection and Data Extraction  We selected all articles that identified or proposed 1 or more QIs to evaluate the quality of care delivered to patients with major traumatic injuries. Minimum inclusion criteria were a description of 1 or more QIs designed to evaluate patients with major traumatic injuries (defined as multisystem injuries resulting in hospitalization or death) and focused on prehospital care, hospital care, posthospital care, or secondary injury prevention.

Data Synthesis  The literature search identified 6869 citations. Review of abstracts led to the retrieval of 538 full-text articles for assessment, of which 192 articles were selected for review. Of these, 128 (66.7%) articles were original research, predominantly trauma database case series (57 [29.7%]) and cohort studies (55 [28.6%]), whereas 37 (19.3%) were narrative reviews and 8 (4.2%) were guidelines. A total of 1572 QIs in trauma care were identified and classified into 8 categories: non-American College of Surgeons Committee on Trauma (ACS-COT) audit filters (42.0%), ACS-COT audit filters (19.1%), patient safety indicators (13.2%), trauma center/system criteria (10.2%), indicators measuring or benchmarking outcomes of care (7.4%), peer review (5.5%), general audit measures (1.8%), and guideline availability or adherence (0.8%). Measures of prehospital and hospital processes (60.4%) and outcomes (22.8%) were the most common QIs identified. Posthospital and secondary injury prevention QIs accounted for less than 5% of QIs.

Conclusions  Many QIs for evaluating the quality of trauma care have been proposed, but the evidence to support these indicators is not strong. Practical recommendations to select QIs to measure the quality of trauma care will require systematic reviews of identified candidate indicators and empirical studies to fill the knowledge gaps for postacute QIs.

Injury is one of the leading causes of death in almost every country in the world. Each year, injuries affect 700 million people around the world and result in more than 5 million deaths.1 However, deaths are only the tip of the injury iceberg. In the United States alone, injured Americans annually make 30 million emergency department visits resulting in 1.9 million hospital admissions at direct medical costs of approximately $80 billion.2 The human and societal burden is even greater, with many survivors never returning to school, work, or their “regular” lives.3,4

Surgical services provide injured patients with pivotal treatment for what is a major cause of morbidity and mortality. However, there is growing evidence that the best treatments and strategies for these patients are not always implemented.5,6 Several studies have documented that as many as half of all patients with major traumatic injuries do not receive recommended care.711 In addition, medical errors are common among critically ill trauma patients.12,13 Review of trauma deaths in hospitals has suggested that between 2.5% and 14% of medical errors are preventable.1419 As a result, the outcomes of patients with major traumatic injuries are not as good as they could be with better translation of the best research evidence at the bedside.

To improve trauma care, the quality of care first needs to be measured using evidence-based tools. However, it is unclear if the proper tools have yet been developed. The purpose of this scoping review was to systematically review the literature on quality indicators (QIs) in evaluating trauma care, identify QIs, map their definitions, and examine the evidence base in support of QIs.

METHODS
SEARCH STRATEGY

Relevant articles were identified by searching the following databases on January 14, 2009, from the first date available: Ovid MEDLINE; Ovid EMBASE; Ovid CINAHL; and Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials. Searches were performed with no language of publication restrictions. Combinations of the following search terms were used: trauma, injury, quality indicator, quality assurance, quality control, performance improvement, quality measure, best practice, and audit. The Cochrane Library was searched separately using the search term trauma. To increase the sensitivity of the search strategy, we also searched the grey literature. This search included identifying and searching Web sites of relevant trauma organizations (American College of Surgeons, American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, American Trauma Society, British Trauma Society, Trauma Association of Canada, Australasian Trauma Society, Orthopedic Trauma Association, Western Trauma Association, Trauma.org, The Society of Trauma Nurses, International Trauma Anesthesia, and Critical Care Society) and Google using combinations of the following search terms: trauma, injury, quality indicator, quality of care, quality assurance, and quality control. In addition, a query was sent to 2 medical librarian listservs (CANMED-LIB and MEDLIB) asking about relevant materials, and responses were collected for 1 week. Appropriate wildcards were used in all searches to account for plural words and variations in spelling. Additional articles were identified by searching the bibliographies of those articles identified in the searches and contacting experts in the field. Selected journals (Journal of Trauma: Injury, Infection and Critical Care, Injury: International Journal of the Care of the Injured, Annals of Surgery, Surgery, and Journal of the American College of Surgeons) were manually searched from August 1, 2006, through July 31, 2007, to ensure that important articles were not missed.

ARTICLE SELECTION

We selected all articles that identified or proposed 1 or more QIs for evaluating the quality of trauma care. We included all articles, both research and nonresearch. For this study, a QI was defined as a performance measure that compared actual care against ideal criteria, a tool to help assess quality of care.20 Minimum inclusion criteria were (1) the article included at least 1 QI; (2) the QI was designed to evaluate the care of patients with major traumatic injuries; and (3) the QI focused on trauma care specific to at least 1 of the following phases of patient care: prehospital, hospital, posthospital, or secondary injury prevention. Injury was defined as the “transfer of energy applied clinically.”21 A major injury was defined as an injury resulting in at least 1 of the following: a multisystem injury (involving ≥2 regions of the body), an Injury Severity Score higher than 9, patient hospitalization, or patient death.22,23 We did not include studies of patients with injuries secondary to poisonings, adverse effects of drugs or biological substances, and isolated hip fractures.22,24 These conservative criteria were chosen because we wanted to optimize our chances for identifying relevant QIs.

ARTICLE REVIEW

Eligible articles were identified through 2 phases. In the first phase, 2 of us (H.T.S. and B.B.-A.) independently reviewed the titles and abstracts of retrieved publications and selected relevant articles for possible inclusion in the review. Disagreements between the 2 assessors were discussed, and, if agreement could not be reached, the article was retained for further review.

In the second phase, the full texts of the remaining articles were independently reviewed by the same 2 authors using forms for determining eligibility criteria. Disagreements between the 2 assessors were discussed, and a third author (S.E.S.) was consulted if agreement could not be reached. Reviewers were not masked to author or journal name.25

Two of us (H.T.S. and B.B.-A.) independently reviewed all full-text articles that satisfied the minimum inclusion criteria and abstracted data using a standardized form. The agreement of the raters was very good (κ = 0.742). Extracted information included QI source, definition (8 components), data sources for measuring QIs, and the articles' authors' recommendations regarding the QI.26 Quality indicators were classified using a prespecified conceptual model that merged the descriptions of the components of a contemporary trauma system, prehospital, hospital, and posthospital care and secondary injury prevention with the 3 components of health care quality in Donabedian's framework: structure, process, and outcome (Table 1).2729 Reviewers also judged whether QIs were operational (yes vs no). Disagreements in assessment and data extraction were resolved by author consensus, and a third author (S.E.S.) was consulted if agreement could not be reached. Owing to the heterogeneity of the results, articles and QIs were summarized as counts and proportions using Stata statistical software, version 10.0 (Stata Corp, College Station, Texas).

RESULTS

The literature search identified 6869 articles. Review of abstracts led to retrieval of 402 full-text articles for assessment plus 72 articles from review of references and 64 articles from the hand search. We identified 192 articles written in 3 languages (English, German, and Spanish) for inclusion in the study (Figure 1).710,12,13,1619,22,27,30209 The most common reason for excluding articles after full-text review was the absence of a QI.

DESCRIPTION OF THE ARTICLES

Table 2 summarizes the characteristics of the articles (see eTable for descriptions of individual articles). Most articles were research studies (66.7%) primarily consisting of case series (29.7%), cohort studies (28.6%), cross-sectional studies (4.2%), and nonrandomized controlled studies (2.6%) using established trauma databases (Table 2). The non–original research articles (33.3%) consisted primarily of narrative review articles (19.3%). Most articles were published in the United States (57.8%) in the last 2 decades. For most articles, the academic status of the corresponding institution was unclear. Few were supported by grants, primarily from the government (14.6%) or private foundations (7.3%).

Most articles focused on QIs to evaluate the quality of trauma care for adult patients, whereas few focused exclusively on pediatric patients (7.8%). The mechanism of injury was not specified in most articles. However, the 3 mechanisms of injury most commonly reported were road traffic accidents (25.5%), falls (17.2%), and violence (16.1%). The anatomical location of patient injuries was reported in some articles (23.4%), with neurological injuries being the most common (14.6%).

DESCRIPTION OF THE QIs

Table 3 summarizes the characteristics of QIs in trauma care. We identified 1572 QIs in the 192 articles, a median of 3 QIs per article (interquartile range, 1-11) with a range of 1 to 60 QIs per article. The QIs were described in the articles using 103 different terms (eg, QI, audit filter, standards for trauma care, safety standard, annual feedback, avoidable factors, criteria deficiencies, etc). The most common source of QIs were authors of articles or local health care provider groups (56.9%), followed by the American College of Surgeons Committee on Trauma (ACS-COT) (26.5%) (Table 3). We reviewed 8 components of QI definitions.26 Virtually all QIs had a descriptive statement (1568 of 1572 [99.7%]), but only a few provided a list of data elements, specifications for data element collection, a description of the population and/or analytic models used to construct the measure, timing of data collection, the format for presentation of the results, and the timing of reporting. The data sources for measuring QIs were specified for 942 indicators (59.9%), with trauma registries (27.2%) and medical record review (24.6%) being the most common sources. After reviewing the definitions and data sources provided for the QIs, the 2 reviewers determined that 959 (61.0%) of the QIs were potentially operational.

Table 4 summarizes the 8 categories for classifying the 1572 QIs based on content matter. The 2 most frequent categories were non–ACS-COT (42.0%) and ACS-COT (19.1%) audit filters. Some QIs related to guideline availability or adherence were identified.

Figure 2 summarizes the distribution of the QIs according to our prespecified conceptual model. Measures of prehospital and hospital processes of care were the most common QIs identified. Posthospital and secondary injury prevention QIs accounted for less than 5% of QIs.

IMPLEMENTATION OF QUALITY INDICATORS

Table 5 summarizes author recommendations regarding use of QIs in trauma care. Authors of the articles recommended that 616 QIs (39.2%) be implemented and used routinely, whereas 78 QIs (5.0%) should not be used. The authors recommended that the QIs be used for quality evaluation in 377 cases (24.0%) and as a quality improvement tool in 308 cases (19.6%). Additional research was recommended for 94 QIs (6.0%) before their implementation in clinical practice. Table 6 lists the 10 QIs identified most frequently in original research studies, which are potential candidates for systematic review and further evaluation.

COMMENT

In our review of the current literature on QIs to evaluate the quality of trauma care, we identified 192 articles and 1572 QIs. A large body of literature exists for evaluating trauma care and may be helpful for guiding development of evidence-based QIs, although few indicators appear to be explicitly defined and supported by valid criteria for collection. The articles available are predominantly focused on prehospital and hospital processes of care for adult populations and provide opportunities for systematic reviews. Very few articles were identified that focused on QIs for evaluating the quality of trauma care for children or postacute care, suggesting a need for empirical research in these domains.

The single most important result from our review is that we did not find a common set of clearly defined, evidence-based, broadly accepted QIs for evaluating the quality of trauma care. Rather, our review identified a large group of heterogeneous indicators that could be broadly categorized into 8 groups. It is not possible to have a transparent, explicit, systematic, data-driven performance measurement feedback system if there are no generally agreed upon measures. How can we explain the contrast between our results and the interest and resources that are being directed toward measuring quality around the globe? Despite its theoretical appeal, developing quality measures is challenging. One, physicians, researchers, and administrators in a field have to communicate using the same language. We identified 103 terms used to identify or describe QIs in our review. Although the field of quality improvement is fundamentally a process of change in human behavior and is driven largely by experiential learning, it would be nearly impossible to effectively communicate with such a large variation in common terms. An agreement on a basic taxonomy is critical similar to the recently published SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines.210 Two, trauma care has until recently been intensively local, with quality improvement based on local surgical audits.211 Quality measures should be developed to serve national goals, but should be implemented locally.26 Our review highlights the frequency with which local QIs have been developed. Three, performance measurement is facilitated with a large, high-quality evidence base. For example, the American College of Cardiology and the American Heart Association have jointly published 11 evidence-based QIs for adults with myocardial infarction.212 These indicators are widely accepted because the underlying data arise from large, multicenter, randomized, controlled trials. Conversely, physicians caring for patients with traumatic injuries do not have the same evidence base to draw upon in developing QIs.213 Four, developing QIs for diseases or disorders that are homogeneous is easier than for those that are heterogeneous.214 Trauma is not a disease but a collection of injuries, and QIs may therefore need to focus on common pathways and outcomes.

Just because a common set of evidence-based QIs of trauma care have not been developed does not mean that they cannot be developed. Recognizing this challenge, the American College of Surgeons has proposed the Trauma Quality Improvement Project,168 modeled after the successful National Surgical Quality Improvement Program,215 a validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. The Trauma Quality Improvement Project is a proposal to measure risk-adjusted performance of trauma centers, identify institutional characteristics associated with good patient outcomes, and promote those institutional characteristics among trauma organizations. A feedback mechanism involving confidential report cards would be used to inform each trauma center of its performance. This proposal is potentially an important step in improving the quality of trauma care because it may provide for the first systematic measuring and reporting of trauma care quality. However, more is needed. Valid measures of structure and process of care are also important because they provide a direct means for programs to evaluate themselves. Finally, outcome measures other than hospital mortality will be needed to capture additional outcome dimensions such as health-related quality-of-life and to provide greater specificity for different components of patient care.141 Our review begins to outline where sufficient literature exists to evaluate candidate indicators (Table 6) and where gaps exist (Figure 2) and empirical research is needed.

There are limitations to this review. First, our search may not have been exhaustive, despite the search of multiple databases using comprehensive search strategies with the assistance of an information specialist and imposing no language restrictions. Nevertheless, it is unlikely that our search missed broad categories of important QIs. Second, it is difficult to extract accurate data from all publications. Some articles are difficult to obtain (3 in our study), some do not disclose all materials or methods used, and results are often unclear and difficult to interpret. Third, categorizing articles by type, even with the assistance of predefined data abstraction tools and classification schemes, is partly subjective.

CONCLUSIONS

We have shown that many QIs for evaluating the quality of trauma care have been proposed but that the distribution of these indicators is skewed across different components of health care quality and trauma systems. Our results should promote future research in 3 areas. First, systematic reviews are warranted to explore whether evidence-based QIs can be developed from the existing literature for acute-care measures. Second, empirical research is needed to fill the knowledge gaps for postacute QIs. Third, research is needed on how QIs are currently used by trauma systems and centers to measure and improve trauma care as a means to better understanding how to effectively incorporate newly developed indicators into performance-improvement initiatives. Identifying, developing, evaluating, and implementing evidence-based QIs is essential to measuring and improving trauma care.

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Article Information

Correspondence: Henry Thomas Stelfox, MD, PhD, Department of Critical Care Medicine, Foothills Medical Centre, University of Calgary, South Tower, Room 1105, 1403-29 St NW, Calgary, Alberta T2N 2T9, Canada (Tom.Stelfox@albertahealthservices.ca).

Accepted for Publication: July 23, 2009.

Author Contributions: Drs Stelfox and Straus had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Stelfox, Nathens, and Straus. Acquisition of data: Stelfox, Bobranska-Artiuch, and Straus. Analysis and interpretation of data: Stelfox, Bobranska-Artiuch, Nathens, and Straus. Draft of the manuscript: Stelfox. Critical revision of the manuscript: Stelfox, Bobranska-Artiuch, Nathens, and Straus. Statistical analysis: Stelfox. Administrative, technical, and material support: Stelfox and Straus. Study supervision: Stelfox.

Financial Disclosure: None reported.

Funding/Support: The project was supported by Synthesis Grant KRS-91770 from the Canadian Institutes of Health Research. Dr Stelfox is supported by a New Investigator award from the Canadian Institutes of Health Research.

Role of the Sponsors: The funding sources had no role in the design, conduct, or reporting of this study.

Additional Contributions: Laure Perrier, MS, assisted with the literature search strategy, and Kelly Mrklas, MSc, assisted with translation of Spanish and German language articles.

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