Trauma PI Blog Post

When Is An Opportunity For Improvement (OFI) Not An OFI?

Opportunity for improvement

In the world of trauma performance improvement, life is just a series of opportunities for improvement (OFI) that need to be identified, fixed, and documented. And there are a never-ending stream of them that must be identified continuously via your normal PI monitoring processes.

When categorizing mortality, the American College of Surgeons Committee on Trauma requires trauma centers to include an indication as to whether any opportunities for improvement were identified. As with anything, there are varying degrees of opportunity. Some are huge, such as blood arriving too late after activation of the massive transfusion protocol. But some would seem to be minor, like a single missed neurologic exam in the ICU.

Flagging OFIs is an important part of the mortality classification process. I have seen a number of trauma centers that categorize their mortalities as having an OFI if even the slightest irregularity was identified. Others claim that the vast majority of their deaths have none. What is the correct way to look at OFIs and decide which ones to include?

The key factor is the clinical significance. Did it harm the patient? Did it have the potential to? If unchecked, could this OFI harm future similar patients? Backing up to my example of the massive transfusion protocol gone wrong, this has the potential to harm every seriously injured patient who requires blood, now and in the future. An OFI of this type must always be pursued and fixed as quickly as possible. A death associated with such an event must be categorized as having opportunity for improvement.

But my other example is more subtle. Suppose the patient involved had an epidural hematoma and was admitted to the ICU for monitoring. The bedside nurse missed a single every-one-hour neuro check, and when he performed the next exam the GCS had declined from 14 to 10. Emergent CT showed expansion of the hematoma with impending herniation. This is an obviously significant OFI, and if the patient died would probably warrant classification as an unanticipated mortality.

However, what if the patient were in the ICU for vital signs monitoring and resuscitation after multiple gunshots to the torso with no history of head injury? A single missed neuro exam is undesirable but not game-changing. Yes, there is the opportunity to counsel the nurse to remind her of the importance of adhering to the written orders. If the patient were to die, this could and should be classified as an anticipated mortality without opportunity for improvement.

In the latter example, I am not implying that an OFI did not exist. It did, and should be acted upon by the PI Program. However, for mortality classification purposes, it is not clinically significant.

Bottom line: Providing clinical care is a complex task. There are hundreds or thousands of things happening in a trauma center that have the potential to alter the clinical care and outcome of your patient. Which means that inevitably something will go wrong. If there was actual or potential harm to this or future patients, that defines a significant opportunity for improvement that must be flagged with the mortality classification.

Michael McGonigal

Michael McGonigal

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