The 2016 Trauma Quality Improvement Program (TQIP) Annual Scientific Meeting and Training, November 5−7 at the Omni Orlando Resort at ChampionsGate, FL, drew nearly 1,600 attendees—the highest number to date—including trauma medical directors, program managers, coordinators, and registrars.
“There are so many people here today—all of whom are committed to the care of the patient,” said Avery Nathens, MD, PhD, FACS, FRCSC, in his opening remarks at the seventh annual meeting. Dr. Nathens is surgeon-in-chief, department of surgery, and medical director, trauma, Sunnybrook Health Sciences Centre, Toronto, ON, and Medical Director of the American College of Surgeons (ACS) Trauma Quality Programs. “We aspire to zero preventable deaths,” he said. “I think, with the degree of commitment in this room, that is possible,” referring to the seminal report released by the National Academies of Sciences, Engineering, and Medicine (NASEM) Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector’s A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury, cosponsored by the ACS. The report calls for eliminating all preventable deaths in both military and civilian trauma patients.
Topics covered at the 2016 TQIP meeting include best practice guidelines for palliative care, an overview of the ACS TQIP Collaboratives program, lessons learned from the Pulse nightclub mass casualty event, and a presentation from trauma survivor-turned-Ironman triathlete Brian Boyle.
Dr. Nathens provided an update on key TQIP initiatives including a new program, Level III TQIP, which launched in July 2016 and extends the program to more levels of care. The program includes access to risk-adjusted benchmarking, opportunities to share best practices, and online education customized to Level III centers.
Dr. Nathens also highlighted the ACS Registries Project, which will migrate all ACS clinical registries into a single platform. “We worked to find a partner to meet the needs of all of the ACS Quality Programs,” he said. “You will see a lot of integration of data across all programs. [However,] I want to make an important clarification—local registries will remain the same. What you will see differently are business intelligence tools that will help you better understand the data. And from a reimbursement standpoint, you will be able to export data to the Surgeon Specific Registry.”
Dr. Nathens also spoke about the TQIP Collaboratives, through which hospitals in either a specified geographic area or a hospital system work together with a shared goal of trauma system quality improvement. At present, Florida, Georgia, Michigan, Pennsylvania, and Texas have TQIP Collaboratives, and North Carolina, parts of California, and the Committee on Trauma (COT) Region III are in the process of forming TQIP Collaboratives.
Another TQIP initiative of note centers on best practice guidelines for managing different patient populations and processes. Past TQIP Best Practice guidelines have included standards for the management of geriatric trauma patients, massive transfusion, traumatic brain injury, and orthopaedic trauma. A new best practices guideline for palliative care will be released in 2017. The next TQIP guideline will focus on imaging in pediatric trauma.
Ronald M. Stewart, MD, FACS, Chair of the COT, noted that the National Academy of Science’s report, Accidental Death and Disability: The Neglected Disease of Modern Society, was released 50 years prior to the TQIP meeting and was the precursor to the NASEM’s 2016 report on achieving zero preventable trauma deaths, as described by Dr. Nathens.
“You know that trauma is the leading cause of death for people under the age of 44,” said Dr. Stewart, professor and chair of the department of surgery, University of Texas Health Science Center, San Antonio. “Trauma accounts for 41 million emergency room visits and 2 million hospital admissions. More than 130,000 Americans die every year as a result of trauma,” he said. “But look at our children—trauma accounts for more deaths in children than all other causes combined.
“When you leave this meeting, we want you to realize that trauma is one of the most critical health problems across the globe…now is the time [for action],” Dr. Stewart said.
A key initiative for the ACS COT in 2016 centers on firearm injury prevention, Dr. Stewart noted. According to a survey of COT members conducted last year, 53 percent of respondents described personal ownership of firearms as “beneficial or generally beneficial.” A total of 88 percent of respondents indicated that the College should give firearm injury prevention top priority. “The COT can serve as a forum for civil, collegial, and professional dialogue on this issue,” he said. “We must identify where we don’t agree and foster a dialogue with the goal of developing creative solutions and consensus,” he added.
Dr. Stewart pointed to the development of the Stop the Bleed program as an initiative that received a “highly enthusiastic response at Clinical Congress .” The goal of the Stop the Bleed campaign was to work with partners from both inside and outside health care to teach all Americans the ABCs of basic hemorrhage control: Alert 911, find the Bleeding injury; and use Compression to stop the bleed.
Dr. Stewart updated attendees on other key COT projects, including the following: The development of Advanced Trauma Life Support® 10th Edition; the Future Trauma Leaders Program; the new Needs Based Assessment of Trauma Systems tool, which helps trauma system leadership answer complex questions surrounding trauma center designation; and the COT’s commitment to implementing the recommendations in the NASEM report on zero preventable deaths from trauma.
Keynote as conversation
The meeting’s keynote address was an unscripted conversation between former Medical Director, ACS Trauma Programs, and former Chair of the COT, J. Wayne Meredith, MD, FACS, and Michael C. Chang, MD, FACS, professor of surgery, Wake Forest Baptist Medical Center, and Chair of the TQIP Committee for the ACS COT. The dialogue focused on the history of early data registries, the Major Trauma Outcome Study (MTOS), the formation of the National Trauma Data Bank (NTDB), and where we are headed in the future.
“The piece you all bring to the table every day is a commitment to the level of data quality and a commitment to getting it right,” said Dr. Meredith, the Richard T. Myers Professor and Chair, department of surgery, Wake Forest School of Medicine; surgeon-in-chief, Wake Forest Baptist Health; and medical director, Childress Institute of Pediatric Trauma, Wake Forest University Baptist Medical Center, Winston-Salem, NC. “You build this up stone-by-stone,” he said. “But you have to use the data or it will fall apart…you can’t just put it up on the shelf.”
Dr. Meredith noted that the first computerized trauma database was established in 1969 at Cook County Hospital, Chicago, IL. It became the model for the Illinois Trauma Registry, collecting data from trauma centers across the state in the early 1970s. In the early 1980s, the ACS COT commissioned the MTOS, which collected data retrospectively from several countries, including the U.S. Survival probability norms were developed via the Revised Trauma Score, the Injury Severity Score, and other criteria.
MTOS ended in 1989, and the COT went on to develop enhanced trauma registry software with the aim of producing what is now known as the National Trauma Data Bank® (NTDB®). “When I first got to the College, the NTDB was [basically] a drawer full of floppy discs,” Dr. Meredith said. He noted that the success of the NTDB and other College-supported trauma projects is the result of leadership from key COT Chairs, including Donald Trunkey, MD, FACS; A. Brent Eastman, MD, FACS; David B. Hoyt, MD, FACS; and John Fildes, MD, FACS.
Dr. Meredith and Dr. Chang concluded the session with a look at where TQIP is headed. Dr. Meredith said population health management (PHM) as an approach to improving patient outcomes and cutting costs would be key to programs such as TQIP. PHM can be used to identify patients in need, as well as better, more cost-effective allocation of resources.
The trauma community needs to look at outcomes other than mortality data, Dr. Meredith added. “We need pragmatic clinical trials. And we need to figure out how to download information from electronic health records [EHR] into the registries,” he said.
Guiding principles of quality improvement
Dr. Hoyt, ACS Executive Director, provided an update on the College quality programs. “Quality has never been more important,” Dr. Hoyt said. “How do you achieve quality? What we are really trying to do is be consistent with our care, and to do that, you need a commitment to the four guiding principles of continuous quality improvement.” These principles include standards supported by research; infrastructure (staffing, equipment, checklists); rigorous data (including post-discharge tracking); and verification. New and notable ACS quality improvement projects include the Strong for Surgery program; the Coalition for Quality in Geriatric Surgery project; the Comprehensive Unit-Based Safety Program for Enhanced Recovery after Surgery; and the soon-to-be-released Resources for Optimal Quality Surgical Care, which covers the five phases of surgery: pre-op, intermediate pre-op, intraoperative, post-op, and post-discharge. “This manual establishes the standards for all of the [College] quality programs,” Dr. Hoyt said.
“We are in uncertain times. We know it. We feel it,” Dr. Hoyt said. “But we are also an enabler of quality care, and we are an irreplaceable catalyst for clinical, educational, and research activities.”
Palliative care: Best practice guidelines
Presenting an overview of palliative care best practice guidelines, Anne C. Mosenthal, MD, FACS, the Benjamin F. Rush Jr. Professor and Chair, department of surgery, The Rutgers New Jersey Medical School, Newark, NJ, and Chair, ACS Committee on Surgical Palliative Care, reminded attendees that “it’s not just about preventing mortality.” Dr. Mosenthal said the guidelines are based on national palliative care quality programs developed by the American Academy of Hospice and Palliative Medicine, the Hospice and Palliative Nursing Association, the National Quality Forum, and others. “The key principle that governs all of these guidelines is that palliative care is delivered in parallel with life-sustaining trauma care throughout the continuum from injury to recovery,” Dr. Mosenthal said. “Best practice requires trauma physicians and nurses to have basic competencies in primary palliative care, pain and symptom management, and end-of-life care.”
A key component of the best practice guidelines is early identification of patients who would benefit from early goals-of-care conversations. This screening is based on the patient’s mortality risk; degree of disabling trauma injury; previous functional status (including one or more serious illnesses, frailty, and age); and an answer to the “surprise question,” which is, “Would you, the physician, be surprised if the patient died within 12 months or before adulthood?”
All elements of the screening tool are organized into three categories: negative screen (non-life threatening trauma, no disabling trauma injuries, no serious or chronic illness); Category 1 positive screen (potential life expectancy under a year or severe functional decline); and Category 2 positive screen (imminently dying or expected outcome is unacceptable to patient). Each category includes corresponding palliative care measures, such as goals of care conversation, comfort measures, Do Not Resuscitate orders, and so on, depending on the level of the injury.
David H. Livingston, MD, FACS, the Wesley J. Howe Professor and chief, trauma, surgical critical care, and acute care surgery, The Rutgers New Jersey Medical School, Newark, said successful guideline application requires buy-in from both the institution and the trauma service. Institutional support should include “training to empower health care providers to be comfortable and competent in providing basic palliative care.” As for the role of the trauma service in guideline implementation, Dr. Livingston said patients should have a palliative care assessment within 24 hours of admission using a tool defined by the institution. He also suggested tagging patients in EHRs to define them as palliative care recipients in order to foster communication across the continuum of care.
Response to the Orlando mass shooting
A panel of staff from the Orlando Regional Medical Center (ORMC) discussed lessons learned from the Pulse nightclub mass shooting June 12, 2016, in the same city that a few months later would host the 2016 TQIP meeting. “This was the deadliest mass shooting in U.S. history to date,” said Joseph A. Ibrahim, MD, FACS, medical director for ORMC, a Level I trauma center. “Many of you in this room reached out to us, and we’ll never forget that.”
Dr. Ibrahim said a successful disaster preparedness plan transforms a mass casualty event—where the number of patients exceeds available medical resources—to a multiple casualty event where patients are successfully managed by mobilizing additional resources. Aided by staff from Arnold Palmer Hospital—the regional pediatric hospital and part of the Level I trauma center—and the Winnie Palmer Hospital for Women and Babies, physicians performed 29 operations and transfused 441 units of blood within the first 24 hours.
“Every hospital must prepare and drill in order to handle the worst that humanity or the environment can produce,” he said. For the last 20 years, ORMC has enhanced its disaster intake plan through rigorous training drills, which are held monthly with emergency medical services personnel, and through process improvements brought about by ORMC’s response to three major hurricanes.
Susan K. Ono, BSN, RN, said ORMC’s close proximity to the Pulse nightclub provided another lesson learned for future mass casualty events. “The nightclub was so close that a lot of patients were able to receive hemorrhage control quickly, allowing for earlier cessation of bleeding and rapid resuscitation.” Ms. Ono noted that bystanders on the scene could have assisted in these efforts had they been trained, underscoring the importance of the Stop the Bleed campaign described earlier.
“We also learned that having a collaborative team is vital to success in stressful situations,” Ms. Ono said, noting that all but one of the trauma surgeons have worked together for the last 10 to 20 years. A total of 471 team members contributed to ORMC’s response, and many staff members performed roles outside of their usual job descriptions, including assisting family members, offloading patients, and helping with environmental services-related tasks. Ms. Ono emphasized the importance of role delineation in managing an effort of this size, as well as the implementation of a tiered staffing model that pairs outside heath care providers with on-staff team members.
“Don’t underestimate your residents,” she added. “Our surgical, orthopaedic, and emergency medicine residents immediately responded and worked tirelessly for the next 36 hours to care for the victims. We would not have been able to respond as we did without them.”
Other ORMC panelists discussed the timeline of events leading up to ORMC’s response, revealed how the facility met Health Insurance Portability and Accountability Act privacy and disclosure challenges while keeping families informed on the status of their loved ones, and highlighted the importance of community support.
“A collaborative is defined as a group of TQIP hospitals working together with the shared goal of system quality improvement,” said Holly Michaels, MPH, Program Manager, ACS Trauma Quality Programs. At present, trauma centers in Florida, Georgia, Michigan, Pennsylvania, and Texas have formed TQIP Collaboratives, and several other entities have expressed interest in the program, including Hospital Corporation of America, COT Region III, and California. To be eligible for the TQIP Collaboratives program, participants must comprise at least three adult Level I or Level II hospitals with the shared goal of system performance improvement.
Primary benefits of the program, according to Ms. Michaels, include semiannual reports that aggregate data from participating hospitals, allowing participants to compare collective collaborative performance with all other TQIP participants. The Collaborative Benchmark Reports provide an opportunity for participants to identify system-wide areas for improvement that may not be easily determined from the perspective of an individual institution. Analytic tools, such as the TQIP Collaborative Driller, are another key benefit of the program. The driller allows collaborative leadership to compare demographic data, injury characteristics, and processes of care.
“We interviewed some of the collaboratives leadership to discover lessons learned,” said Ms. Michaels. “Strong leadership is important to starting a collaborative and gaining momentum.” The interviews also revealed that “increased communication between centers and the sharing of best practices was a fundamental goal of all collaboratives.”
Ms. Michaels also presented the program’s recently retooled tiered fee structure, which makes the TQIP Collaboratives program more accessible to trauma systems of all sizes and configurations, especially smaller trauma systems.
Trauma survivor: Brian Boyle
The final session of the 2016 TQIP meeting featured the perspective of trauma survivor-turned-Ironman competitor, Brian Boyle. In July 2004, on the drive home from swim practice, 18-year-old Mr. Boyle was involved in a near-fatal collision with a speeding dump truck. He lost 60 percent of his blood, his heart was displaced and moved across his chest, and his organs and pelvis were pulverized. He was resuscitated eight times on the operating table before being placed in a medically induced coma. A few months later, Mr. Boyle started blinking his eyelids and eventually emerged from his comatose state. Three years later, he staged a remarkable achievement when he crossed the finish line at the Hawaii Ironman.
“When I was in the coma, I was still very aware,” said Mr. Boyle, who was unable to move or talk but was able to hear, see, and feel pain while he was on life support in the intensive care unit. “Sometimes, I would only have a view of the ceiling, but I could tell whenever someone came in to my room, what their mood was by their tone. Whenever you enter a patient’s room you can have an effect,” said Mr. Boyle, who is currently studying for a Master’s of Health Communication at Johns Hopkins University, Baltimore, MD. “The most important thing for health care providers is to communicate with empathy and compassion.”
His favorite health care providers—his “dream team”—made a point to engage his parents and include them in his treatment plan, which fostered a sense of trust and contributed to his healing process, said Mr. Boyle, who recently published his second book, The Patient Experience: The Importance of Care, Communication, and Compassion in the Hospital Room.
“When I crossed the finish line [at the Ironman], I was representing trauma care providers and all health care providers. You are all miracle workers and guardian angels,” said Mr. Boyle, who will compete in his sixth Ironman event next year.
The eighth annual TQIP Scientific Meeting and Training will take place November 11–13, 2017, at the Hilton Chicago, IL.