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Quality Improvement Guidelines for Burn Center Verification
This document provides additional guidelines regarding the requirements for Quality Improvement Programs as related to burn center verification/ consultation. Effective Quality Improvement Programs may be implemented in diverse ways and the following review is not to be construed as defining absolute requirements but rather is presented so that the goals of the review of key components may be more specifically stated.

The Burn Center Hospital Verification/Consultation Program is designed to assess the institutional organization’s ability and performance as well as its role in regional trauma systems. The verification criteria, as first published in "Hospital and Prehospital Resources for Optimal Care of Patients with Burn Injury: Guidelines for Development and Operation of Burn Centers" in the March/April 1990 issue of the Journal of Burn Care & Rehabilitation established the framework on which the verification visit is based. The bulk of this publication as well as the prereview questionnaire and burn center resources check list which are provided when requesting a verification visit deal with the specifics of organizational structure, personnel qualifications, facilities resources and medical care services. The presence or absence of such components and their importance to the burn care system requires little explanation. These documents also describe the basic requirement for a Quality Improvement Program subdivided by the categories of policies and procedures, weekly patient care conferences, morbidity and mortality conferences and registries and audits. Little information is provided regarding the specifics of Quality Improvement Program requirements compared to the detail of other verification program essentials. Conversely, the review agenda for the verification visit allots 2 1/2 to 3 hours to the review of quality improvements document and patient records out of the 5 hours allotted for the entire verification visit.

This document provides additional guidelines regarding the requirements for Quality Improvement Programs as related to burn center verification/consultation. Effective Quality Improvement Programs may be implemented in diverse ways and this review is not to be construed as defining absolute requirements but is presented so that the goals of the review of key components may be more specifically stated. These key elements include the administrative authority to assume responsibility for the program, specific goals with measurable objectives, a well defined organizational structure and specifically defined standards to determine quality care and outcomes. The goals of a burn Quality Improvement Program are to monitor the process and outcome of patient care, to insure the quality of such care, to improve the knowledge and skills of burn care providers and to provider an institutional structure which promotes quality improvement. During the verification visit, review of the Quality Improvement Program includes review of the minutes of the burn service CQI committee meetings for one year, the quality assurance programs relating to the burn service for one year and specific examples of "closure of the loop" in the Quality Improvement Program. A representative sample of patient charts are requested to review overall care in general and to demonstrate quality improvement review of identified complications in particular.

Policies and Procedures
The governing body of a hospital has the ultimate authority and responsibility for the delivery of quality patient care. An appropriate organizational structure and support for Quality Improvement Programs which integrates the medical staff, its committees and services with the support of the hospital administration is essential. The quality of care of burn patients must be monitored and evaluated such that all pertinent findings of the Quality Improvement Program be reported through channels that ultimately lead to the governing body.

The Burn Center director should have the authority, responsibility and accountability for the assessment and improvement of quality of care related to the burn service. The multidisciplinary nature of burn care requires that representatives from all disciplines participate in the Quality Improvement Program including nursing, physical therapy, occupational therapy, social work, respiratory therapy, nutritional support services and the medical staff. Representatives of these divisions should attend the burn center quality improvement meetings which must be held no less than quarterly.

Quality of Care Assessment

A number of mechanisms are available to evaluate the process of burn care in order to review outcome. These include continuous audits, periodic focused audits, specific case review and trend analysis. Deaths and major complications should mandate specific case review. Complication rates can be monitored by trend analysis over a given interval. The incidence of the complication for a given interval is determined and followed over subsequent intervals. Changes in trends or unexpected variations should initiate a focused audit of those patients developing the complication. Although the clinical activities currently monitored by the quality assurance/CQI program and annual audit criteria are listed under separate sections in the Burn Center Verification documents, these processes are more likely to be part of the whole as recorded in a burn registry.

Audit filters are clinical indicators used to examine the delivery of care and to identify potential patient care problems. Audit filters used by burn centers should be constructed to examine the timeliness, appropriateness and effectiveness of care. The validity of the chosen filters lies in their ability to identify patients at an increased risk of adverse outcome. The continuous or periodic use of these filters in the Quality Improvement Program should be reviewed regularly to access their effectiveness in identifying problems and improving care. The verification review does not require a specific number of filters or define the topics to be reviewed. Examples of such filters for burn center programs include the following:

  • Appropriateness of prehospital fluid and airway management
  • Need for emergency airway management during resuscitative phase
  • Volume of resuscitation fluid required for first 24 hour resuscitation
  • Patients with resuscitation failure
  • Time to first excision and grafting procedure
  • Major complications subcategorized by organ system
  • Infectious complications
  • Graft take less than 80%
  • Adequacy of nutritional supplementation
  • Ventilator days
  • ICU days
  • Total hospital stay
  • Readmission for unexpected problems
  • Mortality
  • Need for reconstructive procedures
  • Return to work

Focused audits may be performed when increased trends are noted in specific adverse outcomes. They may also be used periodically to examine the process of care. Potential examples of focused audits include physician response times, transfer of patients to other facilities prior to the completion of wound coverage, and clinical record documentation of vital signs, the presence of Doppler detected blood flow in circumferentially burned extremities and documentation of pain level determinations.

Patient Care Conferences

Patient care conferences should be held on a weekly basis to review and evaluate the status of each burn patient admitted to the Burn Center Facility. Each clinical discipline should be represented and documentation of their contribution to the treatment plan should be recorded. Such documentation may be in the form of progress notes in the permanent record of each patient or in the form of conference minutes. Those care providers in attendance should be identified by the presence of their signature or by a listing of attendees in the minutes. At the time of the verification visit, the minutes should be available for review or the documentation in the patient’s progress notes should be easily identified.

Morbidity and Mortality Conferences

A Morbidity and Mortality Conference must be held at least monthly and appropriate documentation maintained. An important component of this conference, which reviews all deaths and significant morbid events, includes medical staff peer review. Clinicians other than those regularly caring for burn patients must be involved in this review and the committee should make a judgment about the appropriateness and quality of care in each case of adverse outcome. This has been cited as a deficiency on several verification/consultation visits. The judgment should include the designations, nonpreventable, potentially preventable, or preventable for each case and contributing factors enumerated. Examples of contributing factors include delay in diagnosis, error in diagnosis, error in technique, patient disease, system problem, inadequate protocol and error in judgment or interpretation of diagnostic tests.

The construction of these meetings may take several forms. Commonly, the institution has departmental, i.e. Department of Surgery, Morbidity and Mortality Conferences in which complications are presented from the divisions that make up the department. This format constitutes adequate peer review and the determinations of this committee should be recorded. Since burn care involves a multidisciplinary team, the findings of these conferences should be reported back to the Burn QI Team and the same cases should be reviewed in a multidisciplinary format. Another option for adequate peer review would be to include a nonburn team surgeon in the Multidisciplinary Morbidity and Mortality Conference and judgments regarding appropriateness of care recorded in the minutes of that meeting.
In all cases, the minutes and related proceedings should be forwarded to the governing body of the peer review process for the institution. The peer review process should include a tabulation of the number of problems identified on a quarterly and annual basis. During the verification visits the reviewers will examine the medical records of all patient deaths during the past year. Other selected charts will also be requested. When they review the deaths and other serious complications, documentation that an open, candid discussion of the cases took place in the peer-reviewed conference must be available.

Loop
Closure
When specific problems in patient care or problems in system performance are identified through the quality improvement or morbility and mortality reviews, corrective action in the form of "loop closure" must be taken. Documentation in the minutes of the various meetings should specifically include the method of loop closure for individual cases or for program alterations. Corrective action for problems identified may take place through one of the following mechanisms:

  • Existing policies and procedures that govern or define the standard of care may be altered to correct the problem identified.
  • Professional education: specific cases or system problems may be selected for discussion at the Quality Improvement Committee Meeting, the Morbidity and Mortality Conference or specific conferences selected for team member education. Such education may be addressed to the entire group of providers or to specific providers as appropriate.
  • Professional counseling: review of a specific case or cases is made by the burn center director with the individual physician, nurse or other care provider. This process of evaluation and counseling should be documented carefully.
  • System problems involving the pre burn center phase of treatment may be addressed in the form of letters or documented telephone calls to referring physicians, local EMS and aeromedical transport personnel.
  • System problems which involve institutional practices not under Burn Center control, such as the performance of consulting or ancillary services should be addressed through memoranda to the specific director of those programs. 

QII records should document that "loop closure" has dealt with the problem identified.

Annual Review

The minimum components for review on an annual basis to be performed by the burn center include burn severity, burn mortality and length of hospitalization. A review of the hospital charges for care are desirable but not essential at this time. The hospital Quality Improvement Committee should oversee the QI process of the Burn Center Multidisciplinary Team and the Morbility and Mortality peer review on an annual basis. Such a review insures that the burn center quality improvement process legitimately fulfills its mission of quality improvement.

Burn Registry Participation

Participation in a burn registry is a required component for burn center verification. Use of a registry will facilitate system audits and monitoring of complications. Additionally, as more participants submit data to a national data bank, a method of external comparison will become available much as the National Trauma Registry is used for outcome determination in the trauma patient population. Appropriate segregation of patient groups based on extent of burn, age and preexisting and concomitant co-morbid conditions will permit more precise filters for adverse outcome than could be obtained by data from single institutions. Such cooperation will also help fulfill the goal of the verification process regarding the development of standards for burn care from within the community of burn center professionals. Participation in the ABA/ACS sponsored TRACS program is encouraged, but not required. A minimal data set is being developed which will facilitate collection of key data elements by cooperating burn centers.

Thanks to David W. Mozingo, MD, FACS for his development of the Quality Improvement Guidelines for Burn Center Verification. Dr. Mozingo is the chair of the ABA Committee on Organization and Delivery of Burn Care.