Pediatric Trauma Care: Reducing Length of Stay with Change Model

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Copyright © 2019 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited. 84 WWW.JOURNALOFTRAUMANURSING.COM Volume 26 | Number 2 | March-April 2019 QUALITY IMPROVEMENT P ediatric trauma centers enlist a variety of resources to provide optimal care to injured children with improvements in outcomes and survival ( Densmore, Lim, Oldham, & Guice, 2006 ; Potoka et al., 2000 ; Segui-Gomez et al., 2003 ). In evaluating pediatric trauma centers, the American College of Surgeons Com- mittee on Trauma (ACS COT) emphasizes the nature of trauma as a surgical disease best managed by surgical services with the consultation of medical specialists. As part of the ACS COT trauma verification process, pediat- ric trauma surgeons are expected to direct care for more than 90% of the injured children admitted to the hospital (ACS COT, 2014 ). For a variety of reasons, including the low number of ACS-verified pediatric trauma centers in the United States, 90% of pediatric trauma patients receive their care at nonpediatric trauma facilities ( Osler et al., 2001 ; Segui-Gomez et al., 2003 ). In an effort to impact this reality, the New York State Department of Health adopted the ACS COT standards for verification as a means for designating trauma centers in New York State in 2012 (Abd El-Shafy, Savino, Christopherson, & Prince, 2017 ). For established pediatric trauma programs, making per- manent and meaningful change can be a difficult and challenging problem. Successful change comes through the use of a planned approach utilizing change management frame- work. Kurt Lewin’s 3-Step Change Model is a commonly used systematic approach focused on human resourc- es and how they impact the change process (Shirey, 2013). Lewin’s research into group behavior identified that an individual leader among the group needs to view the present situation as being sustained by forces and behaviors from within the group in order to initi- ate change (Burnes, 2004). This individual is referred to as the change leader. Lewin stated that if you could ABSTRACT Although often cared for nonoperatively, trauma is a surgical disease managed by surgical services in a multidisciplinary manner. The American College of Surgeons Committee on Trauma (ACS COT) emphasizes this as part of the ACS COT verification process and expects nonsurgical service admission rate of less than 10%. In this project, we developed a collaborative care model captained by surgical services with medical service consultation to achieve this goal for optimal care of injured patients. The project was conducted at a freestanding pediatric trauma center undergoing verification as a Level 1 ACS COT pediatric trauma center. The trauma registry was utilized to obtain nonsurgical service admission rate from January 2011 to June 2015. Lewin’s 3-Step Model was utilized to guide change. Adherence to the new ACS standards was continually tracked and fallouts were addressed on an individual basis. Overall compliance was reported routinely through trauma and hospital quality programs. Individual successes and accomplishments were recognized and reinforced. At the inception of the project, nonsurgical admission rate was 30%. Implementation of Lewin’s 3-Step Model nonsurgical admission rate decreased to 3%, representing a reduction of 27%. In addition, a 21% reduction in hospital length of stay, 3.78–3 days, was demonstrated with no change in 30-day readmission rate. Lewin’s change model facilitated culture change to achieve ACS COT standards and reduced nonsurgical admissions to less than 10%. Reduction in hospital length of stay supports an improvement in the efficiency of care when directed by the pediatric trauma surgery team. Key Words Lewin’s 3-Step Model, Nonsurgical service admission, Trauma verification Author Affiliations: Cohen Children’s Medical Center, Northwell Health, New Hyde Park, New York (Drs Abd el-shafy and Prince, Mss Zapke and Sargeant, and Mr Christopherson); Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York (Drs Abd el-shafy and Prince); Northwell Health Trauma Institute, Manhasset, New York (Dr Prince and Mr Christopherson); and Maimonides Medical Center, Brooklyn, New York (Dr Abd el-shafy). The authors declare no conflicts of interest. Correspondence: Nathan A. M. Christopherson, MBA, Department of Pediatric Trauma Surgery, Cohen Children’s Medical Center, 269-01 76th Ave, New Hyde Park, NY 11040 ( nchristop1@northwell.edu). Decreased Pediatric Trauma Length of Stay and Improved Disposition With Implementation of Lewin’s Change Model Ibrahim Abd el-shafy, MD ■ Jennifer Zapke, RN ■ Danielle Sargeant, NP ■ Jose M. Prince, MD ■ Nathan A. M. Christopherson, MBA DOI: 10.1097/JTN.0000000000000426

Copyright © 2019 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited. JOURNAL OF TRAUMA NURSING WWW.JOURNALOFTRAUMANURSING.COM 85 identify these forces, you could not only identify the manner in which a group behaves but also identify the forces that would need to be targeted to bring about change. To impact these forces, Lewin developed the 3-Step Change Model: unfreezing, moving, and refreez- ing (Burnes, 2004) First, the group must go through an unfreezing process where the current balance must be interrupted in order for a new process to be learned; the unfreezing step is often the most difficult of the change process (Burnes, 2004). Once a change leader has been able to break the status quo, the group is ready for what Lewin refers to as the moving phase. During this second phase, the change leader must seize the motivation that has been created during the first stage and provide guidance to move the group toward the end goal. Having motivated the group toward the goal, further reinforcement is needed for sustainment (Burnes, 2004). The final stage of the change process is solidifying the change or as Kurt Lewin refers it to— refreezing. The refreezing stage is essential to prevent a group from reverting back to old behaviors. Through continued positive reinforcement, the new status quo will effectively create a culture change (Burnes, 2004). As our quality improvement project focuses on chang- ing the culture of admission patterns focusing on in- dividual providers, we felt that Lewin’s theory was an ideal model. We hypothesized that the application of Lewin’s Change Model would effectively drive institutional change as re- flected by a decrease in the nonsurgical trauma admission rate and better align resources to provide care for injured children at a pediatric trauma center. METHODS This quality improvement project was conducted at a freestanding pediatric trauma program established in 1996. The pediatric trauma program underwent a con- sultation visit by the ACS COT in 2012 and a subsequent verification visit in 2015. The institution is an ACS COT Level 1 pediatric trauma center with more than 800 pa- tients registered annually. The Northwell Health Insti- tution Review Board approved this investigation as an exempt project. All data were obtained from the institu- tional trauma registry, Trauma One by Lancet Technol- ogy, Boston, Massachusetts. Initial data were obtained in 2011 to evaluate preintervention nonsurgical service admission rate. Analysis of 2011 data identified that pa- tients not requiring immediate surgical intervention by the pediatric surgery team and patients with single sys- tem injuries were primarily being admitted to nonsurgi- cal services. Using Lewin’s 3-Step Model to guide change, the trau- ma program became the project leader with the trauma program manager overseeing data gathering and analysis and the trauma medical director leading change with the involved medical providers. Identifying the issues within the current practice requiring change was the first step in the process. Using the data captured in our trauma registry, we created reports to identify the providers admitting patients to the nonsurgical services. Meetings were arranged with the involved providers to gain knowl- edge and understand their current practice while work- ing to discover any barriers that would prevent change. As we have demonstrated in other aspects of pediatric trauma care, open and ongoing communication with the involved providers is essential in defining what change is actually needed within the organization ( Abd El-Shafy et al., 201 8). During unfreezing, education on ACS COT standards and model for a new collaborative approach for patient management was provided to all providers in- volved in caring for injured patients. The trauma medical director spoke directly with the medical services listening to their apprehension for change and concerns regard- ing previous change attempts and culture of the hospital. Through active listening, the Trauma Medical Director validated their concerns and held surgical providers ac- countable for their actions. Through listening to and en- gaging involved providers, we started to break down the cultural barrier to change. Once all involved providers were educated, the next step in our process was to anchor the changes into the hospital’s culture—sustainment can be the most difficult part of the process. Compliance was monitored on an ongoing basis and identified cases were addressed with immediate follow-up to involved providers. The trauma registrar and the performance improvement coordina- tor conduct daily rounds and identify any nonsurgical admissions while the patient is still in-house for imme- diate correction. To enforce the process change, edu- cation was provided at the monthly resident meetings and it has been incorporated into the resident trauma orientation program. An annual trauma manual that is disseminated to all employees has been updated to in- clude the guidelines for admission of a patient who sus- tained a traumatic injury; it is also presented to all new hires during their trauma orientation. During the change process. adherence to standards was continually tracked from 2011 to 2016 and fallouts were addressed on an individual basis. Data were collect- ed and presented during monthly leadership meetings to inform the staff of project progress. Global e-mails were sent to providers and staff who do not regularly attend trauma meetings recognizing their efforts and updating them on our progress. Through mass communication, everyone was constantly informed of where the hospital was on adopting the new standard and how quality of patient care had improved. Champions were identified from each discipline to reinforce the change within their

Copyright © 2019 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited. 86 WWW.JOURNALOFTRAUMANURSING.COM Volume 26 | Number 2 | March-April 2019 department. During the transition, providers often ques- tioned the need for change, and what was wrong with the standard of practice that had been adopted over the past 20 years of our trauma program. Rationale for the new standards was explained in detail. Providers often stated that the original institutional practice of admitting patients to nonsurgical services had been developed because of resistance from surgeons to admit the pa- tients. Education was provided to all the departments and services, the standard was explained, and support was gained. Providers were reassured that surgeons understood the process change and any instances of confrontation should be immediately reported. Leader- ship acted on all reports and provided follow-up with involved providers demonstrating commitment and sup- port. As progress was made and publicly recognized, the project moment increased and further support and buy- in were achieved. Administrative buy-in is crucial to the change process and without their support; change ini- tiatives often fail (Burnes, 2004). When New York State Department of Health adopted the ACS COT standards, the Northwell Health System envisioned that they would be a leader in trauma care and the successful verification of trauma centers became a key corporate initiative. The adoption of this new initiative provided the motivation to facility leadership to support the ACS standards and commit to success in the verification process. The big- gest support during the change process at our institu- tion came from the chief medical officer (CMO). The CMO worked side by side with the trauma program and held division chiefs accountable for compliance with admitting injured patients to surgical services. The sup- port received from the CMO gave precedence to practice changes that would lead to success. During the solidify- ing stage, project success was recognized by hospital leadership and involved parties were thanked for their hard work and dedication to the project. Adherence tracking was moved from monthly to quarterly presenta- tions and individual follow-up contained as needed. RESULTS 1. Lewin’s 3-Step Model resulted in a sustained reduction in nonsurgical admission of injured children at a pediatric trauma center . The initial nonsurgical service admission rate was greater than 29% in 2011, with 148 patients out of 512 admitted to nonsurgical services. Unstructured early attempts to influence change were ineffective at creating a long-term cultural change. Using Lewin’s 3-Step Model trauma program leadership developed a change management plan to change current culture. Since implementation, the nonsurgical admission rate significantly decreased to less than 5% in 2016, with 39 patients out of 781 admitted to nonsurgical services (Figure 1). The process change has been sustained for more than 2 years since implementation. 2. Process changes associated with ACS COT Level 1 pediatric verification and reductions in nonsurgical admission rate were also marked by a reduction in inpatient hospital length of stay for admitted pediatric trauma patients . As a result of this cultural change, there was a 21% reduction in hospital length of stay from 3.78 days to 3 days on average from 2011 to 2016 (Figure 2). Figure 1. Nonsurgical admission rates demonstrate a decrease with implementation of the American College of Surgeons Committee on Trauma guidelines while utilizing Lewin’s Change Theory.

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Copyright © 2019 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited. JOURNAL OF TRAUMA NURSING WWW.JOURNALOFTRAUMANURSING.COM 87 and became empowered to immediately address non- surgical admissions and transfer patients to the pediatric surgery service. This new process has been very effec- tive in closing the gap between the old standard and the new one. Among the limitations of this project, we made a significant number of changes to adapt to the ACS COT guidelines for a Level 1 pediatric trauma cent- er, which makes it difficult to define if reduction in hospital length of stay is directly the result of in- creased admission and direction of care by surgeons. In fact, one might question the true benefit of main- taining a nonsurgical admission rate of less than 10%. Some have suggested that trauma patients who do not require surgical care are better suited to be admitted to the medical service following evaluation by the trauma team ( Tutunjian, Bugaev, Breeze, Arabian, & Rabino- vici, 2017). One study even reported similar outcomes by hospitalists trained in family medicine or emergen- cy medicine compared with Level 1 trauma centers in patients with mild to moderate trauma (Orlando et al., 2012). Ultimately, it continues to be a benchmark set by the ACS COT. CONCLUSION At a single, freestanding Level 1 pediatric trauma center, we demonstrated that implementation of ACS COT stand- ards resulted in a decreased nonsurgical admission rate and hospital length of stay despite no significant change in ISS severity. Our findings support that Lewin’s change theory may prove to be a useful tool in implementing an enduring programmatic change. 3. Increased admission to surgical services of pediatric trauma patients did not increase hospital readmission rates . During this time, there was no change in 30-day readmission rate ( Figure 3 ). To further validate our results, we looked at the injury severity score (ISS) and did not identify a significant change during the project period. In 2011, 57 patients with ISS greater than 15 were treated, whereas in 2015 it was 53 patients. DISCUSSION Using Lewin’s change theory, we report a successful ap- proach to implementing and sustaining change to adapt a pediatric trauma center. These changes resulted in a reduction of nonsurgical admission of trauma patients by 30%. Furthermore, we identified a reduction of pa- tient length of stay by 21% during this same period of time. Throughout the process, nursing was empowered to speak up and bring to the attention of the physicians when a patient was admitted to the wrong service. At any time during a patient’s hospital stay, he or she could be transferred to the appropriate service with the prop- er physician acceptance and sign-out. Pediatric surgery fellows were invaluable throughout the change process KEY POINTS • Lewin’s 3-Step Model results in a sustained reduction in nonsurgical admission of injured children at a pediatric trauma center. • Process changes associated with ACS COT Level 1 pediatric verification and reductions in nonsurgical admission rate were also marked by a reduction in inpatient hospital length of stay for admitted pediatric trauma patients. • Increased admission to surgical services of pediatric trauma patients did not increase hospital readmission rates. Figure 2. Hospital length of stay decreased from 3.78 to 3 days from 2012 to 2015. Figure 3. Thirty-day readmission rate. REFERENCES Abd El-Shafy, I. A., Delgado, J., Akerman, M., Bullaro, F., Christopherson, N. A. M., & Prince, J. M. (2018). Closed-loop communication improves task completion in pediatric trauma resuscitation. Journal of Surgical Education, 75 (1), 58–64. Abd El-Shafy, I., Savino, J., Christopherson, N. A. M., & Prince, J. M. ( 2017 ). Reduction of pediatric pedestrian hazardous road conditions in a school drop-off zone using video review . The Journal of Trauma and Acute Care Surgery , 83 (5S Suppl. 2 ), S227–S232.

Copyright © 2019 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited. 88 WWW.JOURNALOFTRAUMANURSING.COM Volume 26 | Number 2 | March-April 2019 American College of Surgeons Committee on Trauma . (2014). Resources for optimal care of the injured patient . Chicago, IL : American College of Surgeons . Burnes, B. (2004 ). Kurt Lewin and the planned approach to change: A re-appraisal . Journal of Management Studies , 41 (6), 977–1002. Densmore, J. C., Lim, H. J., Oldham, K. T., & Guice, K. S. ( 2006). Outcome and delivery of care in pediatric injury . The Journal of Trauma and Acute Care Surgery , 41 , 92–98. Orlando, A., Salottolo, K., Uribe, P., Howell, P. A., Slone, D. S., & Bar-Or, D. ( 2012 ). A 5-year review of a trauma-trained hospitalist program for trauma patients: A matched cohort study . Surgery , 152 (1), 61 –68 . Osler, T. M., Vane, D. W., Tepas, J. J., Rogers, F. B., Shackford, S. R., & Badger, G. J. ( 2001). Do pediatric trauma centers have better survival rates than adult trauma centers? An examination of the National Pediatric Trauma Registry . Journal of Trauma , 50 (1), 96 –101 . Potoka, D. A., Schall, L. C., Gardner, M. J., Stafford, P. W., Peitzman, A. B., & Ford, H. R. (2000). Impact of pediatric trauma centers on mortality in a statewide system . Journal of Pediatric Surgery , 49 , 237–245. Segui-Gomez, M., Chang, D. C., Paidas, C. N., Jurkovich, G. J., Mackenzie, E. J., & Rivara, F. P. (2003). Pediatric trauma care: An overview of pediatric trauma systems and their practices in 18 US states. Journal of Pediatric Surgery , 38 (8), 1162–1169. Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource . Journal of Nursing Administration , 43 (2), 69–72. doi:10.1097/NNA.0b013e31827f20a9 Tutunjian, A. M., Bugaev, N., Breeze, J. L., Arabian, S. S., & Rabinovici, R. (2017). Is it safe to admit patients with acute injuries to nonsurgical services? A retrospective review. The American Journal of Surgery , 213 (6), 1098–1103.

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