Outcomes in Trauma Centers and Leapfrog Safe Practices Survey

Mortality rates vary greatly among trauma centers in the United States; trauma patients admitted to high-mortality hospitals have a 70% greater risk of dying compared with trauma patients admitted to average hospitals. This variance offers an opportunity for researchers to examine the association between specific processes of care and outcomes; measuring performance can enable hospitals to identify and implement best practices to improve outcomes. According to researchers, “national initiatives to measure and promote the adoption of evidence-based measures provide an opportunity to assess the impact of these best practices on trauma outcomes in the real world.” The researchers cited the Leapfrog Group, which evaluates hospital adherence to a set of Safe Practices for Better Healthcare, endorsed by the National Quality Forum (NQF) as part of a national strategy to improve patient safety and healthcare quality. The researchers recently conducted a retrospective cohort study to examine the association between self-reported hospital compliance with the NQF safety practices and outcomes (inhospital mortality and hospital-associated infection [HAI] rates) in trauma centers. Patients were considered to have an HAI when coded as having either (1) sepsis, (2) pneumonia, (3) Staphylococcus infection, or (4) Clostridium difficile–associated disease. The study utilized the 2006 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Study results were reported in Archives of Surgery [2011;146(10):1170-1177]. The NQF list of safe practices includes computerized physician order entry (CPOE), intensivist staffing of intensive care units (ICUs), measures to ensure the adequacy and competence of the nursing workforce as well as the nonnursing direct care workforce, use of prevention measures for ventilator-assisted pneumonia and central venous catheter bloodstream infections, and teamwork training. The 2007 Leapfrog Hospital Quality and Safe Practices Survey (SPS) data include information on the 30 individual NQF safe practices and a weighted composite safety score based on 27 safe practices. The current study cohort included patients admitted to a hospital with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of trauma; patients with burns or unspecified injuries were excluded, as were those with late effects of injury, superficial injuries, or foreign bodies. The final cohort consisted of 42,417 patients in 58 level I and level II hospital trauma centers. Approximately half (53%) of the trauma centers were teaching hospitals, most (79%) were nonprofit, and they were nearly equally distributed across geographic regions (Northeast, 22%; South, 17%; Midwest, 22%; West, 38%). Most of the patients were male (59.1%), and the median age of the patients in the cohort was 47 years. The most frequent (47.5%) mechanism of injury was blunt trauma, followed by low fall (18.2%) and motor vehicle accident (17.2%). Overall mortality for the sample was 3.15%. Following adjustment for potential patient- and hospital-level confounders, the total score on the SPS was not associated with mortality (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.79-1.06) or HAI (aOR, 1.03; 95% CI, 0.81-1.29; P=.25). Separate patient-level multivariate logistic regression models were estimated to examine the association between each of the outcome variables and total score on the SPS, ICU physician staffing, COPE, and scores on the individual components of the SPS. Only 1 of the individual patient safety practices in the SPS was associated with mortality: disclosure of adverse events was predictive of lower mortality (aOR, 0.87; 95% CI, 0.80-0.95; P<.001). Pressure ulcer prevention (aOR, 1.35; 95% CI, 1.11-1.66; P=.003), prevention of wrong site surgery (aOR, 1.17; 95% CI, 1.02-1.33; P=.02), and prevention of myocardial infarction (aOR, 1.11; 95% CI, 1.01-1.22; P=.03) were associated with a greater likelihood of HAIs. Prevention of anticoagulation adverse events was associated with a lower risk of HAI (aOR, 0.89; 95% CI, 0.81-0.97; P=.009). Full implementation of CPOE was not associated with reduced mortality (aOR, 1.03; 95% CI, 0.75-1.42; P=.86) or with a lower risk of HAIs (aOR, 0.94; 95% CI, 0.57-1.56; P=.82). Full implementation of ICU physician staffing was not predictive of mortality (aOR, 1.13; 95% CI, 0.90-1.28; P=.30) or HAI (aOR, 1.04; 95% CI, 0.76-1.42; P=.81). The researchers concluded that they were “unable to detect evidence that hospitals reporting better compliance with the National Quality Forum patient safety practices had lower mortality or a lower incidence of hospital-associated infections.”