title: Application of International Classification Injury Severity Score to National Surgical Quality Improvement Program defines pediatric trauma performance standards and drives performance improvement.
abstract: BACKGROUND
  The American College of Surgeons National Surgical Quality Improvement Program is becoming a core methodology to define performance as a ratio of observed to expected events. We hypothesized that application of this using International Classification of Injury Severity Score (ICISS) for individual patient risk stratification to a group of hospitals contributing data to the National Pediatric Trauma Registry (NPTR) would apply objective evidence of actual injuries to define an expected standard and identify performance outliers.
  
  
  METHODS
  Using a blinded code, children entered into phase III of the NPTR were aggregated by treating hospital. Individual patient ICISS survival probability (Ps) were calculated using survival risk ratios (SRR) derived from the phase II NPTR dataset (n = 53,253). For each center, sample size, observed mortality, and ICISS Ps were calculated. Probability of mortality (Pm) was computed as 1 - Ps. Logistic regression was used to develop a predictive model for mortality. Logit transformation of Pm was performed to adjust for the skew of minor injury in children and reduce overestimation of low Pm fatalities. Mean Pm was computed for each center and multiplied by its volume to determine expected frequency. Observed to expected ratio (O/E) and 95% confidence interval were calculated to define expected performance and outliers above or below 1 SD of the mean O/E.
  
  
  RESULTS
  Patients treated at 30 pediatric trauma centers (mean volume = 451 +/- 258/patients per center) were evaluated. Mean O/E was 1.001 with SD = 0.404. Twenty-two centers fell within the reference range; O/E of 12 centers exceeded 1, suggesting performance below expectation. Trauma center volume, as reflected by sample, did not correlate to O/E performance.
  
  
  CONCLUSIONS
  Application of ICISS Ps from a national pediatric benchmark population simplifies determination of expected mortality necessary to compute the expected component of National Surgical Quality Improvement Program. Analysis of these ratios of expected to observed mortality demonstrates variance among centers, defines performance against peers using the same benchmarks, and can drive performance improvement based on the objective evidence of injury diagnoses actually encountered.
authors: Department of Surgery, University of Florida Health Science Center, Jacksonville, Florida, USA. jjt@jax.ufl.edu
authors: Joseph J
authors: JJ
authors: Tepas
authors: Brian G
authors: BG
authors: Celso
authors: Cynthia L
authors: CL
authors: Leaphart
authors: Darrell
authors: D
authors: Graham
mesh_terms: D002648:Child; D017052:Hospital Mortality / Q000639:trends; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D015601:Injury Severity Score; D015397:Program Evaluation / Q000639:trends*; D011785:Quality Assurance, Health Care / Q000379:methods*; D013531:Surgicenters / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D014947:Wounds and Injuries / Q000145:classification* / Q000401:mortality / Q000601:surgery