Do contradictions in TQIP measures affect perceptions of quality. An analysis of TQIP definitions on quality outcomes for placement of ICP monitoring at a single level one trauma center

Background: TQIP quality measures as currently defined on occasion provide discordant conclusions. A recent TQIP report of an urban level one-trauma center suggested a low employment of ICP monitoring while also demonstrating aggressive implementation of ICP monitoring (ave. within 90 min of arrival). This apparent contradiction leads to the question; Does TQIP define correctly the patient cohort who would most benefit from ICP monitoring?

Methods: A retrospective IRB approved review of all patients reported to TQIP with severe TBI was performed at an ACS verified level one trauma center. All patients admitted to the TS during the TQIP study period were reviewed. Demographic data as well as AIS, ISS, GCS, injury type and outcomes were reviewed. Data were reported as aggregate.

Results: Trauma registry review determined 108 patients met the TQIP definition for severe TBI. Analysis of these patients revealed only 58%(63) met clinical criteria for severe TBI. In this group 45.4%(49) suffered non-survivable TBI. ICP monitoring was not initiated in this subgroup of patients. 42%(45) of the patients were determined to have mild to moderate TBI. In this cohort the initial GCS reported in the trauma registry overestimated the severity of the TBI in 19.4%(21) of the patients. ICP monitoring was initiated 29%(30) patients. The analysis would indicate 13%(14) would have benefited from ICP monitoring indicating an 15%(16) over utilization. The majority of these patients sustained meaningful neurologic recovery indicating a better-defined criterion may be necessary to determine when ICP monitoring is a quality indicator.

Conclusion: This study indicates the current TQIP definition used to justify ICP monitoring appears to overestimate the number of patients who would benefit from ICP monitoring. The corrected quality analysis indicates an overutilization rather than an underutilization of ICP monitoring. Further study of the effect of definitions on quality measures should be considered.