On Their Feet, Still at Risk: Trauma in Self-Presenters

General Information

Institution Name: MetroHealth Parma Medical Center

Authors: Jennifer Haven BSN, RN, CCRN, EMT-B – Trauma Program Manager, Vanessa Ho MD, PhD, MPH, FACS – Trauma Medical Director, Cristina Nickell MPH, BSN, RN, CCRN, Karen Silberhorn RHIT, CSTR, CAISS, Arnav Mahajan MB, Jesse Scheider MSN, RN, RNC-OB, C-EFM, Brooke Rayokovich PA-C, MSPAS, Waseem Khawaja MD, MPH, MS, MHCM, FACEP, FACHE, Laura Schmidt MSN, BSN, RN, CEN, NEA-BC, Michelle Dudas MSN, RN, NEA-BD

Name of Case Study: On Their Feet, Still at Risk: Trauma in Self-Presenters

Identification of Local Problem

Despite their ability to walk into the Emergency Department (ED) at MetroHealth Parma Medical Center, some patients may still suffer from significant traumatic injuries that require immediate medical attention. However, in the first quarter of 2024, data revealed that approximately 18% of patients meeting trauma activation criteria were either missed or experienced delays in activation. This oversight can result in critical delays in diagnosis and treatment. A key contributing factor is that the initial point of contact—the front-desk greeter—is not medically trained, which limits their ability to identify patients in need of urgent trauma evaluation.

Context of the QI Activity

To address missed or delayed trauma activations in self-presenting patients, we implemented three targeted interventions.

Interventions

Enhanced front-end screening, real-time case review and feedback, and implementation of a ‘split-flow triage’ model.

Implementation Strategy

1. Enhanced Front-End Screening: Recognizing that the front-desk greeter is not medically trained, we integrated a brief set of trauma screening questions into their standard intake process. These questions are designed to identify high-risk patients whose injuries may not be immediately apparent, prompting earlier clinical triage, thus reducing the risk of delayed trauma team activation.
2. Real-Time Case Review and Feedback: The Trauma Program Manager (TPM) began conducting concurrent reviews of cases involving missed or delayed activations. This allowed for the identification of trends and immediate feedback. The TPM collaborated closely with the Emergency Department Nurse Manager to address concerns, reinforce trauma activation criteria, and provide timely education to staff.
3. Implementation of a ‘Split-Flow Triage’ Model: The Emergency Department introduced a new triage approach known as ‘Split-Flow,’ which categorizes incoming patients based on acuity and injury risk. This model facilitates earlier involvement of clinical staff and ensures that patients meeting trauma criteria are identified and managed promptly.

Costs and Funding Sources 

Implementation of the split‑flow triage model required dedicated staffing resources, including the creation of new FTEs for 1 RN, 2 paramedics, and 2 PCNAs during peak operational hours. These positions were funded through the Emergency Department’s operational budget, supported by institutional investment in improving patient throughput, safety, and early clinical engagement. No trauma‑program funds were used for this initiative, as the model was developed and implemented independently by the ED. Ongoing costs are incorporated into routine staffing expenditures, with anticipated benefits in efficiency, patient flow, and timely identification of high‑acuity patients.

Overall Results and Analysis 

To evaluate the effectiveness of our interventions, we utilized a multi-layer monitoring and review process:

1. Time-to-Activation Tracking: The trauma program has established benchmarks for the time interval between patient arrival and trauma team activation. Trauma data specialists record these metrics in the trauma registry, enabling consistent tracking and analysis.
2. Ongoing Monitoring and Review: The Trauma Program Manager (TPM) regularly monitors activation times and investigates any delays. These cases are reviewed monthly in collaboration with the Trauma Medical Director (TMD) during secondary case reviews to identify patterns and opportunities for improvement.
3. Daily Census Review: Registry staff conduct daily reviews of the emergency department census to identify potential missed trauma activations. The TPM reviews this list weekly, and any patients retrospectively meeting activation criteria are added to the registry for further evaluation.
4. Performance Reporting: Data on delays and missed activations are compiled and presented at regular Performance Improvement and Patient Safety (PIPS) meetings. This ensures transparency, accountability, and continuous quality improvement.

Q1: The year began with the highest number of missed/delayed activations (44) and the highest average percentage (18%) based on all eligible trauma activations.

Q2: After the introduction of enhanced screening, there was a notable improvement, with missed/delayed activations dropping to 33 and the percentage falling to 11%. [insert figure labeled “TQIP first to second quarter graph”]

Q3: With the launch of split-flow triage, the trend continued downward – missed/delayed activations dropped to 23 and the percentage to 8%.

Q4: The best performance was achieved in the final quarter, with only 11 missed/delayed activations and an average of just 4% of all eligible trauma activations.

Limitations

The Split-Flow triage model, launched in October 2024, operates daily from 0900-1900 and is supported by six full-time equivalents (FTEs), including nurses, paramedics and patient care nursing assistants (PCNAs). An advanced practice provider is also integrated into the team, reflecting a coordinated, multi-level approach to patient care.

A key limitation of this model is its reliance on dedicated staffing. The Emergency Department must consistently schedule and utilize split-flow personnel to maintain the intended level of early clinical engagement and throughput efficiency. Because dedicated split‑flow staff are not available between 1900 and 0900, the department must rely on enhanced front‑end screening and real‑time case review with immediate feedback to identify and address any overnight clinical or operational concerns. This creates variability in workflow and places additional demands on overnight staff, who must uphold split‑flow principles without the full team structure in place.

Lessons Learned 

Sustainability was driven by strong interdepartmental collaboration. The MetroHealth Simulation Center played a pivotal role in preparing staff through targeted training sessions prior to implementation. In parallel, the Emergency Department and Trauma Program partnered to ensure that Split-Flow staff were proficient in trauma activation criteria and workflows, reinforcing consistency and readiness across teams.

To maintain continuity of trauma screening outside of Split-Flow operating hours, the front-desk greeter continues to incorporate brief trauma screening questions into their workflow. Because Split-Flow operates only staffed from 0900 to 1900 – our peak volume hours – this process helps ensure early identification of potential trauma cases during overnight and lower-volume periods. When any screening question is answered affirmatively, the greeter promptly alerts the clinical triage team, enabling timely escalation and evaluation regardless of the time of day.

This initiative demonstrates how cross-functional teamwork – spanning clinical, operational, and educational departments - can drive and sustain meaningful improvements in trauma care delivery. The coordinated efforts across teams not only supported successful implementation but also established a foundation for long-term reliability and adaptability. Although several interventions were introduced, the Split-Flow Triage Model likely had the greatest impact because it improved early recognition of trauma risk at the point of entry. By categorizing patients based on acuity and injury risk, it supported earlier clinical involvement and more timely escalation of patients meeting trauma criteria. The 88% reduction seen after implementation suggests that this change was a major contributor to the improvement.