Performance Improvement (PI) Monitoring

POPULATION OF INTEREST

All patients with diagnosis of limb amputation or limb amputation procedure code.

INTENT (EXPECTED OUTCOMES)

1. Amputation wounds are not closed at the initial operation.
2. Circular/guillotine amputation is avoided (viable soft tissue is preserved).
3. Repeat debridement/dressing change within 24 hours of first debridement/amputation procedure.
4. Document if patient received antibiotic beads or topical antibiotic (this PI metric is for tracking purposes and does not imply it is a requirement).

PERFORMANCE/ADHERENCE METRICS

1. Number and percentage of patients in the population of interest who have amputation wounds left open at initial operation (closed flap amputation at first procedure = non-adherence).
2. Number and percentage of patients in the population of interest who underwent a non-guillotine or non-circular amputation.
3. Number and percentage of patients in the population of interest who have their dressing change/repeat debridement within 24 hours of initial amputation/procedure.
4. Number and percentage of patients that received antibiotic beads or topical antibiotic. (This PI metric is for tracking purposes and does not imply it is a requirement).

DATA SOURCE

- Patient Record
- DoDTR

SYSTEM REPORTING & FREQUENCY

The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting may be performed as needed.

The system review and data analysis will be performed by the JTS Chief and the JTS PI Branch.

RESPONSIBILITIES

It is the trauma team leader’s responsibility to ensure familiarity, appropriate compliance, and PI monitoring at the local level with this CPG.