Process Improvement


The Process Improvement Committee is charged with evaluating regional trauma registry

data to identify trends and opportunities for improvement.

The make-up of the committee is defined in HFS Rule 118 and the committee can convene

in closed session to review protected case information.


NCRTAC Performance Improvement Confidentiality Statement (Please complete annually)


American College of Surgeons PI Manual

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Wisconsin Regional PI Guideline Document


The Wisconsin Trauma Registry has been overhauled over the last few years and hospitals

are busy entering data. The RTACs can now get regional reports about trauma trends and

issues in their area as well.


Performance Improvement Committee current review areas include:


  • Amount of time a patient stays at a Level III or IV trauma center before transfer to a Level II
  • Use of antibiotics for open fractu


Previous projects:


  • Padding of patients transferred on a backboard
  • Prehospital scene interval
  • Prehospital Glasgow Coma Score documentation
  • Critical patients transferred to a Level II trauma center after multiple transfers or admission to a Level III or IV trauma center.


Scroll down for information on our current projects.


ED LOS>3 Hours


The Emergency Department Length of Stay greater than 3 hours project monitors the percentage of seriously injured trauma patients that stay at the referring hospital for more than 3 hours prior to transfer to one of the Level II trauma centers in our region. Referring hospitals are asked to do process improvement case reviews for these cases. The information is forwarded to the NCRTAC PI committee to identify trends. The information is also entered into the State PI committee database.



Padding of patients transferred on a backboard


When patients are transferred between hospitals while still immobilized on a backboard it is critical to pad the backboard to prevent pain and skin breakdown. This project monitors the percentage of patients transferred on a backboard with padding in place.

The NCRTAC has purchased Back Rafts and distributed them to area hospitals to support the project.

Click here for an educational video about application of the Back Raft in the hospital setting.