Current Trauma Reports

, Volume 4, Issue 1, pp 9–24 | Cite as

Quality and Patient Safety Indicators in Trauma and Emergency Surgery: National and Global Considerations

  • Jordan D. Bohnen
  • Geoffrey A. Anderson
  • Haytham M. A. KaafaraniEmail author
Patient Safety and Quality in Trauma (H Kaafarani, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Patient Safety and Quality in Trauma


Purpose of Review

This review focuses on quality and patient safety indicators in trauma and emergency surgery in the developed and developing world.

Recent Findings

Quality and patient safety indicators have proliferated in recent years. There is significant variability in the strength of evidence behind existing measures, as well as variability in their acceptance and utilization.


This review article highlights the evolution quality and patient safety indicators using examples from both the developed and the developing world. The authors include recommendations for future efforts to utilize and implement such indicators in trauma and emergency surgery. One key remaining challenge remains the development of meaningful, streamlined, and consensus-based performance metrics that simultaneously assess variations in quality and safety while also being easily measurable so as not to overly burden the people and systems tasked with collecting this important information.


Quality indicators Patient safety Trauma systems Emergency surgery Global surgery Low- and middle-income countries (LMIC) 


Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Weir S, Salkever DS, Rivara FP, Jurkovich GJ, Nathens AB, Mackenzie EJ. One-year treatment costs of trauma care in the USA. Expert Rev Pharmacoecon Outcomes Res. 2010;10(2):187–97. Scholar
  2. 2.
    • Shafi S, Aboutanos MB, Agarwal S Jr, Brown CV, Crandall M, Feliciano DV, et al. AAST Committee on Severity Assessment and Patient Outcomes. Emergency general surgery: definition and estimated burden of disease. J Trauma Acute Care Surg. 2013;74(4):1092–7. This article describes the American Association for the Surgery of Trauma’s (AAST) comprehensive effort to produce a consensus-based definition of Emergency General Surgery (EGS). A complete list of ICD-9 codes that comprise the scope of primary EGS diagnoses is provided. This publication can be used as the basis for further efforts aimed at creating and studying quality indicators in EGS. CrossRefPubMedGoogle Scholar
  3. 3.
    Gale SC, Shafi S, Dombrovskiy VY, Arumugam D, Crystal JS. The public health burden of emergency general surgery in the United States: a 10-year analysis of the Nationwide inpatient sample—2001 to 2010. J Trauma Acute Care Surg. 2014;77(2):202–8.CrossRefPubMedGoogle Scholar
  4. 4.
    • Sangji NF, Bohnen JD, Ramly EP, Yeh DD, King DR, deMoya M, et al. Derivation and validation of a novel Emergency Surgery Acuity Score (ESAS). J Trauma Acute Care Surg. 2016;81(2):213–20. The Emergency Surgery Score is a recently described and validated scoring system for predicting perioperative morbidity and mortality for emergency general surgery patients. The Emergency Surgery Score holds promise as a tool to facilitate quality benchmarking in EGS. CrossRefPubMedGoogle Scholar
  5. 5.
    Bohnen JD, Ramly EP, Sangji NF, de Moya M, Yeh DD, Lee J, et al. Perioperative risk factors impact outcomes in emergency versus non-emergency surgery differently: time to separate our national risk-adjustment models? J Trauma Acute Care Surg. 2016;81(1):122–30. Scholar
  6. 6.
    Ingraham AM, Cohen ME, Bilimoria KY, Raval MV, Ko CY, Nathens AB, et al. Comparison of 30-day outcomes after emergency general surgery procedures: potential for targeted improvement. Surgery. 2010;148(2):217–38. Scholar
  7. 7.
    Havens JM, Peetz AB, Do WS, Cooper Z, Kelly E, Askari R, et al. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg. 2015;78(2):306–11. Scholar
  8. 8.
    Codman EA. A study in hospital efficiency: as demonstrated by the case report of the first five years of a private hospital. Boston: Th. Todd co.; 1918.Google Scholar
  9. 9.
    Continuous BDM. Improvement as an ideal in health care. N Engl J Med. 1989;320(1):53–6.CrossRefGoogle Scholar
  10. 10.
    Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard medical practice study I. N Engl J Med. 1991;324(6):370–6. Scholar
  11. 11.
    Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard medical practice study II. N Engl J Med. 1991;324(6):377–84. Scholar
  12. 12.
    Davies SM, Geppert J, McClellan M, McDonald KM, Romano PS, Shojania KG. Refinement of the HCUP quality indicators, technical reviews, No. 4. UCSF-Stanford Evidence-based Practice Center. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001.Google Scholar
  13. 13.
    Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy; 2000.Google Scholar
  14. 14.
    Institute of Medicine. Crossing the quality chasm. Washington, DC: National Academy; 2001.Google Scholar
  15. 15.
    Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678–86. Scholar
  16. 16.
    McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–45. Scholar
  17. 17.
    Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA. 2006;295(3):324–7. Scholar
  18. 18.
    Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB, et al. The Department of Veterans Affairs NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program Ann Surg. 1998;228(4):491–507.PubMedGoogle Scholar
  19. 19.
    Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg. 2009;250(3):363–76. Scholar
  20. 20.
    Cohen ME, Liu Y, Ko CY, Hall BL. Improved surgical outcomes for ACS NSQIP hospitals over time: evaluation of hospital cohorts with up to 8 years of participation. Ann Surg. 2016;263(2):267–73. Scholar
  21. 21.
  22. 22.
    Sangji NF, Bohnen JD, Ramly EP, Velmahos GC, Chang DC, Kaafarani HMA. Derivation and validation of a novel physiological emergency surgery acuity score (PESAS). World J Surg. 2017;41(7):1782–9. Scholar
  23. 23.
    National Quality Forum. Measure evaluation criteria., accessed 9/24/17.
  24. 24.
    Dimick JB. What makes a “good” quality indicator? Arch Surg. 2010;145(3):295. Scholar
  25. 25.
    Agency for Healthcare Research and Quality, Prevention quality indicators:, accessed October 9, 2017.
  26. 26.
    Agency for Healthcare Research and Quality, Inpatient quality indicators:, accessed October 9, 2017.
  27. 27.
    Agency for Healthcare Research and Quality, Patient safety indicators:, accessed October 9, 2017.
  28. 28.
    Agency for Healthcare Research and Quality, Pediatric quality indicators:, accessed October 9, 2017.
  29. 29.
    Agency for Healthcare Research and Quality, National Quality forum endorsed individual and composite measures:, accessed October 11, 2017.
  30. 30.
    Rosen AK, Loveland S, Shin M, Shwartz M, Hanchate A, Chen Q, et al. Examining the impact of the AHRQ patient safety indicators (PSIs) on the veterans health administration: the case of readmissions. Med Care. 2013;51(1):37–44. Scholar
  31. 31.
    Kaafarani HM, Borzecki AM, Itani KM, Loveland S, Mull HJ, Hickson K, et al. Validity of selected patient safety indicators: opportunities and concerns. J Am Coll Surg. 2011;212(6):924–34. Scholar
  32. 32.
    Rosen AK, Itani KM, Cevasco M, Kaafarani HM, Hanchate A, Shin M, et al. Validating the patient safety indicators in the Veterans Health Administration: do they accurately identify true safety events? Med Care. 2012;50(1):74–85. Scholar
  33. 33.
    Borzecki AM, Kaafarani H, Cevasco M, Hickson K, Macdonald S, Shin M, et al. How valid is the AHRQ patient safety indicator “postoperative hemorrhage or hematoma”? J Am Coll Surg. 2011;212(6):946–953.e1–2.CrossRefPubMedGoogle Scholar
  34. 34.
    Borzecki AM, Kaafarani HM, Utter GH, Romano PS, Shin MH, Chen Q, et al. How valid is the AHRQ patient safety indicator “postoperative respiratory failure”. J Am Coll Surg. 2011;212(6):935–45. Scholar
  35. 35.
    Utter GH, Borzecki AM, Rosen AK, Zrelak PA, Sadeghi B, Baron R, et al. Designing an abstraction instrument: lessons from efforts to validate the AHRQ patient safety indicators. Jt Comm J Qual Patient Saf. 2011;37(1):20–8. Scholar
  36. 36.
    Romano PS, Mull HJ, Rivard PE, Zhao S, Henderson WG, Loveland S, etal. Validity of selected AHRQ patient safety indicators based on VA National Surgical Quality Improvement Program data. Health Serv Res 2009;44(1):182–204, DOI:
  37. 37.
    Kaafarani HM, Rosen AK Using administrative data to identify surgical adverse events: an introduction to the patient safety indicators. Am J Surg 2009;198(5 Suppl):S63–S68, DOI:
  38. 38.
    Utter GH, Zrelak PA, Baron R, Tancredi DJ, Sadeghi B, Geppert JJ, et al. Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator. Ann Surg. 2009;250(6):1041–5. Scholar
  39. 39.
    Narain W. Assessing estimates of patient safety derived from coded data. J Healthc Qual. 2017;39(4):230–42. Scholar
  40. 40.
    Ang D, McKenney M, Norwood S, Kurek S, Kimbrell B, Liu H, et al. Benchmarking statewide trauma mortality using Agency for Healthcare Research and Quality's patient safety indicators. J Surg Res. 2015;198(1):34–40. Scholar
  41. 41.
    Glance LG, Dick AW, Meredith JW, Mukamel DB. Variation in hospital complication rates and failure-to-rescue for trauma patients. Ann Surg. 2011;253(4):811–6. Scholar
  42. 42.
    Ramanathan R, Leavell P, Stockslager G, Mays C, Harvey D, Duane T. Validity of Agency for Healthcare Research and Quality patient safety indicators at an academic medical center. Am Surg. 2013;79:578–82.PubMedGoogle Scholar
  43. 43.
    Morris BJ, Richards JE, Archer KR, Lasater M, Rabalais D, Sethi MK, et al. Improving patient satisfaction in the orthopaedic trauma population. J Orthop Trauma. 2014;28(4):e80–4. Scholar
  44. 44.
    Committees on Trauma, Blue Book: a guide to organization objectives activities, American College of Surgeons, 2007.Google Scholar
  45. 45.
    MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366–78. Scholar
  46. 46.
    Mackenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. The national study on costs and outcomes of trauma. J Trauma. 2007;63(6 Suppl):S54–67. discussion S81–6CrossRefPubMedGoogle Scholar
  47. 47.
    Hospital resources for optimal care of the injured patient. Prepared by a task force of the committee on trauma of the American College of Surgeons. Bull Am Coll Surg. 1979;64(8):43–8.Google Scholar
  48. 48.
    Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW Jr, et al. The major trauma outcome study: establishing national norms for trauma care. J Trauma. 1990;30(11):1356–65. Scholar
  49. 49.
    Glance LG, Dick AW, Mukamel DB, Osler TM. Association between trauma quality indicators and outcomes for injured patients. Arch Surg. 2012;147(4):308–15. Scholar
  50. 50.
    Nayduch D, Moylan J, Snyder BL, Andrews L, Rutledge R, Cunningham P. American College of Surgeons trauma quality indicators: an analysis of outcome in a statewide trauma registry. J Trauma. 1994;37(4):565–73; discussion 573-5. Scholar
  51. 51.
    Willis CD, Stoelwinder JU, Cameron PA. Interpreting process indicators in trauma care: construct validity versus confounding by indication. Int J Qual Health Care. 2008;20(5):331–8. Scholar
  52. 52.
    • Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE. Quality indicators for evaluating trauma care: a scoping review. Arch Surg. 2010;145(3):286–95. This comprehensive review article summarizes available literature on quality indicators in trauma care through 2010. The authors identify 1572 trauma-related quality indicators across 192 articles and classify them along several different domains. Strengths and weaknesses of existing QIs are highlighted, along with recommendations for improvement of trauma care and research related to fQIs. CrossRefPubMedGoogle Scholar
  53. 53.
    Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44(3):166–206.CrossRefGoogle Scholar
  54. 54.
    Moore L, Stelfox HT, Boutin A, Turgeon AF. Trauma center performance indicators for nonfatal outcomes: a scoping review of the literature. J Trauma Acute Care Surg. 2013;74(5):1331–43. Scholar
  55. 55.
    Moore L, Lauzier F, Stelfox HT, Le Sage N, Bourgeois G, Clément J, et al. Complications to evaluate adult trauma care: an expert consensus study. J Trauma Acute Care Surg. 2014;77(2):322–9; discussion 329-30. Scholar
  56. 56.
    Moore L, Lauzier F, Stelfox HT, Kortbeek J, Simons R, Bourgeois G, et al. Validation of complications selected by consensus to evaluate the acute phase of adult trauma care: a multicenter cohort study. Ann Surg 2015;262(6):1123–1129, DOI:
  57. 57.
    Shafi S, Nathens AB, Cryer HG, Hemmila MR, Pasquale MD, Clark DE, et al. The trauma quality improvement program of the American College of Surgeons Committee on trauma. J Am Coll Surg. 2009;209(4):521–30 e1. Scholar
  58. 58.
    Nathens AB, Cryer HG, Fildes J. The American College of Surgeons trauma quality improvement program. Surg Clin North Am. 2012;92(2):441–54, x-xi. Scholar
  59. 59.
    Hemmila MR, Nathens AB, Shafi S, Calland JF, Clark DE, Cryer HG, et al. The trauma quality improvement program: pilot study and initial demonstration of feasibility. J Trauma. 2010;68(2):253–62. Scholar
  60. 60.
    Shafi S, Nathens AB, Parks J, Cryer HM, Fildes JJ, Gentilello LM. Trauma quality improvement using risk-adjusted outcomes. J Trauma. 2008;64(3):599–604; discussion 604-6. Scholar
  61. 61.
    American College of Surgeons National Trauma Data Standard:, accessed October 12, 2017.
  62. 62.
    Hemmila MR, Jakubus JL, Cain-Nielsen AH, Kepros JP, Vander Kolk WE, Wahl WL, et al. The Michigan trauma quality improvement program: results from a collaborative quality initiative. J Trauma Acute Care Surg. 2017;82(5):867–76. Scholar
  63. 63.
    Hemmila MR, Cain-Nielsen AH, Wahl WL, Vander Kolk WE, Jakubus JL, Mikhail JN, et al. Regional collaborative quality improvement for trauma reduces complications and costs. J Trauma Acute Care Surg. 2015;78(1):78–85. discussion −7CrossRefPubMedGoogle Scholar
  64. 64.
    Becher RD, Meredith JW, Chang MC, Hoth JJ, Beard HR, Miller PR. Creation and implementation of an emergency general surgery registry modeled after the National Trauma Data Bank. J Am Coll Surg. 2012;214(2):156–63. Scholar
  65. 65.
    Ingraham A, Nathens A, Peitzman A, Bode A, Dorlac G, Dorlac W, et al. American Association for the Surgery of Trauma emergency general surgery quality indicator development expert panel. Assessment of emergency general surgery care based on formally developed quality indicators. Surgery. 2017;162(2):397–407. Scholar
  66. 66.
    Peponis T, Bohnen JD, Sangji NF, Nandan AR, Han K, Lee J, et al. Does the emergency surgery score accurately predict outcomes in emergent laparotomies? Surgery. 2017;162(2):445–52. Scholar
  67. 67.
    Nandan AR, Bohnen JD, Sangji NF, Peponis T, Han K, Yeh DD, et al. The emergency surgery score (ESS) accurately predicts the occurrence of postoperative complications in emergency surgery patients. J Trauma Acute Care Surg. 2017;83(1):84–9. Scholar
  68. 68.
    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9. Scholar
  69. 69.
    Mukhopadhyay S, Lin Y, Mwaba P, Kachimba J, Makasa E, Lishimpi K, et al. Implementing world health assembly resolution 68.15: national surgical, obstetric, and anesthesia strategic plan development—the Zambian experience. Bull Am Coll Surg. 2017;102(6):28–35.PubMedGoogle Scholar
  70. 70.
    • Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624. In 2013, The Lancet called for the establishment of a Commission on the neglected topic of Global Surgery. Over the next 2 years, leaders from around the world met to define the state of surgery around the world and define plans for the improvement of the delivery of surgical care, especially in the poorest areas of this world. This publication represents the summary of years of effort by hundreds of clinicians, researchers, ministers of health, policy workers and thought leaders. CrossRefPubMedGoogle Scholar
  71. 71.
    Haider A, Scott JW, Gause CD, Mehes M, Hsiung G, Prelvukaj A, et al. Development of a unifying target and consensus indicators for global surgical systems strengthening: proposed by the global alliance for surgery, obstetric, trauma, and Anaesthesia care (the G4 alliance). World J Surg 2017.Google Scholar
  72. 72.
    Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score J Trauma. 1987;27(4):370–8.PubMedGoogle Scholar
  73. 73.
    Kobusingye OC, Lett RR. Hospital-based trauma registries in Uganda. J Trauma. 2000;48(3):498–502. Scholar
  74. 74.
    Spence RT, Chang DC, Kaafarani HMA, Panieri E, Anderson GA, Hutter MM. Derivation, validation and application of a pragmatic risk prediction index for benchmarking of surgical outcomes. World J Surg. 2017;Google Scholar
  75. 75.
    Gruen RL, Gabbe BJ, Stelfox HT, Cameron PA. Indicators of the quality of trauma care and the performance of trauma systems. Br J Surg. 2012;99(Suppl 1):97–104. Scholar
  76. 76.
    Kardooni S, Haut ER, Chang DC, Pierce CA, Efron DT, Haider AH, et al. Hazards of benchmarking complications with the National Trauma Data Bank: numerators in search of denominators. J Trauma. 2008;64(2):273–7; discussion 7-9. Scholar
  77. 77.
    Osborne NH, Nicholas LH, Ryan AM, Thumma JR, Dimick JB. Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. JAMA. 2015;313(5):496–504. Scholar
  78. 78.
    Etzioni DA, Wasif N, Dueck AC, Cima RR, Hohmann SF, Naessens JM, et al. Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. JAMA. 2015;313(5):505–11. Scholar
  79. 79.
    Berwick DM. Measuring surgical outcomes for improvement: was Codman wrong? JAMA. 2015;313(5):469–70. Scholar
  80. 80.
    Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE. A systematic review of quality indicators for evaluating pediatric trauma care. Crit Care Med. 2010;38(4):1187–96. Scholar
  81. 81.
    Stelfox HT, Straus SE, Nathens A, Gruen RL, Hameed SM, Kirkpatrick A. Trauma center quality improvement programs in the United States, Canada, and Australasia. Ann Surg. 2012;256(1):163–9. Scholar
  82. 82.
    Agency for Healthcare Research and Quality, Patient Safety Indicators Appendices, Appendix G, Trauma Diagnosis Codes:, accessed October 10, 2017.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Jordan D. Bohnen
    • 1
  • Geoffrey A. Anderson
    • 1
  • Haytham M. A. Kaafarani
    • 1
    Email author
  1. 1.Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of SurgeryMassachusetts General Hospital and Harvard Medical SchoolBostonUSA

Personalised recommendations