Using a FOCUS-PDCA quality improvement model for applying the severe traumatic brain injury guidelines to practice: process and outcomes
- Mary Kay Bader, RN, MSN, CCRN, CNRN,
- Sylvain Palmer, MD, FACS,
- Connie Stalcup, RN, MSN,
- Thomas Shaver, MD, FACS
- Mission Hospital Regional Medical Center Mission Viejo, California, USA
Trauma teams strive to provide care based on best practice. Exploring the clinical outcomes of patients sustaining severe traumatic brain injury (TBI) at our trauma centre from 1994–97 we found that the outcomes were marginal at best: 43% of our patients expired and 30% suffered severe disability. These results were consistent with those of some studies on TBI published in the 1980s. Researchers in the past decade have used new technology for monitoring the effects of secondary brain injury and examined the effects of various treatment modalities on the outcomes of patients with TBI. In 1995, the American Association of Neurological Surgeons (AANS) evidence-based clinical guidelines for managing severe TBI were published.1 The guidelines recommended changes in the care of patients with TBI and challenged caregivers to evaluate their practices and examine the clinical outcomes of this high risk group.
Motivated by the new practice recommendations and the potential for greatly affecting patient outcomes, Mission Hospital Regional Medical Center’s (MHRMC) multidisciplinary neurotrauma team convened in 1997 to begin performance improvement. Current practice was examined and new hospital based clinical guidelines were developed. Numerous changes were recommended as the team dismantled current practice patterns and constructed new care priorities. The result was a series of algorithms with established outcomes at every phase of the patient’s hospital course. Four years after integrating the changes in practice, the team evaluated prospectively collected data to determine outcomes for patients with severe TBI. Current outcomes (2001 data) indicated that 72.8% of patients had a good outcome (no disability to moderate disability), 13.6% had severe disability to persistent vegetative state, and 13.6% died. We will present a FOCUS-PDCA performance improvement approach to show the processes used to apply national scientific guidelines to the clinical setting. Statistical analysis using an ordinal regression model will show outcome …