The 2017 Trauma Quality Improvement Program (TQIP) Annual Scientific Meeting and Training, November 11−13 in Chicago, IL, drew nearly 1,650 attendees—a 15 percent increase from 2016 and the highest number to date—including trauma medical directors, program managers, coordinators, and registrars.
Highlights of the eighth annual TQIP meeting include a keynote presentation titled Increasing Survival from Active Shooter and All Severe Hemorrhagic Events by Lenworth M. Jacobs, Jr., MD, MPH, FACS, vice-president of academic affairs and chief academic officer at Hartford Hospital, Hartford, CT; updates and progress reports on TQIP and Committee on Trauma (COT) initiatives; an overview of American College of Surgeons (ACS) military partnerships specifically related to National Academies of Science, Engineering, and Medicine (NASEM) report activities; a session summarizing teamwork essentials for the trauma team; and a presentation from trauma survivor Noah Galloway, who lost an arm and a leg in an improvised explosive device attack during Operation Iraqi Freedom in December 2005.
Empowering the public to Stop the Bleed
Citing a Texas State University and U.S. Federal Bureau of Investigation (FBI) study, Dr. Jacobs outlined active shooter incidents with the highest casualty counts between 2000 and 2013, including Cinemark Century 16 Theater, Aurora, CO (12 killed and 58 wounded); Virginia Polytech Institute, Blacksburg (32 killed and 17 wounded); and Sandy Hook Elementary School, Newtown, CT (27 killed and 2 wounded).
“These children did not go to school to be shot, they went to school to learn,” Dr. Jacobs said, referring to the Sandy Hook event, which proved to be the tipping point for the ACS and other organizations to begin considering ways to improve survival from these situations.
“If you can stay alive for 10 to 25 minutes, you are probably going to be okay. The duration of the Virginia Tech event was eight to nine minutes, with 174 rounds shot. The event at Fort Hood lasted 10 minutes, with 214 rounds shot. In Las Vegas, more than 1,000 rounds were shot, and it was over in 10 minutes. Civilians had to make life-or-death decisions, and therefore, they should be engaged in training and decision making. Our mantra is to inform, educate, and empower,” said Dr. Jacobs, chair of the Hartford Consensus Joint Committee to Enhance Survivability from Active Shooter and Intentional Mass Casualty Events, and a Regent of the College.
“The mission is to keep the blood in the body any way that you can,” he said.
Dr. Jacobs also described how the efforts of the U.S. military’s Tactical Combat Casualty Care (TCCC) program led to a renewed focus on prehospital tourniquet use. Before TCCC guidelines were introduced, military medics were instructed to use a tourniquet only as a final measure to stem extremity hemorrhage. After widespread implementation of TCCC tourniquet recommendations, deaths from extremity hemorrhage decreased significantly, Dr. Jacobs said, citing a comprehensive study of 4,596 U.S. combat fatalities from 2001 to 2011, which found that the incidence of preventable deaths from extremity hemorrhage had decreased to 2.6 percent. “This data is very powerful information to take to the decision makers of the U.S.,” he said.
After the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events was convened by the ACS in April 2013 in collaboration with representatives from the medical community, the National Security Council, the U.S. military, the Federal Bureau of Investigation, and others, the committee developed a set of recommendations collectively known as the Hartford Consensus. The primary aim of the Hartford Consensus is to prevent anyone from dying from uncontrolled bleeding.
A national Hartford Consensus survey assessed the general public’s interest in acting as immediate responders, with 92 percent of respondents indicating they would be very likely or somewhat likely to try to control bleeding in someone they did not know. The survey results, according to Dr. Jacobs, suggested a need for strategies to educate laypeople in hemorrhage control, which led to the launch of the Stop the Bleed® campaign in October 2015. Bleeding control kits, a key component of this initiative, contain pressure bandages, hemostatic dressings, tourniquets, and gloves. “We patterned the kits off of the U.S. military. They have tested and deployed this equipment with positive results,” he said.
As of November 2017, more than 8,000 instructors and more than 100,000 participants worldwide have been trained in Stop the Bleed principles, Dr. Jacobs said.
“Inspiring quality: Better standards, better outcomes—but how do we it?” said Avery Nathens, MD, PhD, FACS, FRCSC, in his opening remarks. “We do this through the four pillars of quality: setting standards, building the right infrastructure, using robust data, and verifying that everyone is consistent with those standards.” Dr. Nathens is surgeon-in-chief, department of surgery, medical director, trauma, Sunnybrook Health Sciences Centre, Toronto, ON; and Medical Director, ACS Trauma Quality Programs.
The College’s Quality Programs touch 2,800 hospitals around the world, according to Dr. Nathens, and lead to greater access to surgical care, fewer complications, and improved outcomes in the areas of trauma, cancer, breast care, bariatric surgery, and overall surgical care. He highlighted several recent initiatives that support the work of these programs, including the publication of the Optimal Resources for Surgical Quality and Safety manual (the red book), which describes key concepts in quality, safety, and reliability to ensure patient-centered care.
Dr. Nathens also described the QuintilesIMS (now called IQVIA) partnership with the ACS, which provides a “common data platform that will provide a shared data infrastructure across ACS Quality Programs and new and enhanced business tools,” he said, including tools for advanced data validation business intelligence. He noted the favorable reviews from initial pilot testers, including comments describing how easy the reports were to decipher, how the data displayed seamlessly via Excel spreadsheets, and how users were able to navigate quickly through the validation summary report, allowing them to identify and fix errors. He emphasized that local registries would remain the same, but other factors might change, including program nomenclature and definitions, as well as corrective actions and resolution timeframes.
Dr. Nathens also outlined plans for revising the Resources for Optimal Care of the Injured Patient manual. “We are focused on revising standards in the ‘orange book,’ and we put forward specific goals. First, we are going to drop criteria that are burdensome and that have limited patient benefit. We are also going to incorporate clarifications and prioritize changes based on evidence and expert opinion. Perhaps most importantly, we are going to be a bit broader in terms of input. In the past, it was a small committee, but now we have [representatives] from PIPS [the ACS COT Performance Improvement and Patient Safety Program], TQIP, VRC [ACS COT’s Trauma Center Verification, Review, and Consultation], and STN [the Society of Trauma Nurses] providing many perspectives, with changes that are hopefully more meaningful in terms of improving patient care.”
Another important component of Dr. Nathens’ TQIP update focused on the ACS TQIP Benchmark Report released in the fall of 2017, which is based on admissions from 2016 and the first quarter of 2017 from 466 TQIP centers. “This is the first year where we focused on AIS [abbreviated injury scale] 2005, which is a shift from AIS 1998 and affects adult, Level III, and collaborative reports,” Dr. Nathens said. He noted the 2017 report features an expanded section on orthopaedic trauma care, with a greater focus on tibia shaft fractures.
Dr. Nathens also highlighted TQIP best practice guidelines for managing different patient populations and processes, including the recently released ACS TQIP Palliative Care Best Practices Guidelines, which was released in November 2017 and provides health care professionals with evidence-based recommendations regarding the care of the trauma patient. A new best practices guideline on imaging is due in early 2018, according to Dr. Nathens. Future best practices guidelines will cover nonaccidental trauma such as child abuse and elder abuse.
In addition, Dr. Nathens outlined key recommendations in the NASEM report, particularly Recommendation 5, which calls for military and civilian trauma systems to collect and share common data spanning the continuum of care.
“Is there life after discharge? An estimated 50 percent suffer from chronic pain, 40 percent suffer from anxiety or depression, and 25 percent have post-traumatic stress disorder. We have to change our notion of trauma beyond ‘alive or dead.’ Traumatic injury is a complex, chronic disease…and we have to figure out what we can do in the acute phase of care that will improve these outcomes,” Dr. Nathens said.
Ronald M. Stewart, MD, FACS, Chair of the COT, provided an overview of key COT initiatives, including the new 10th edition of the Advanced Trauma Life Support® (ATLS®) program, which he called “the most exciting update since its inception.” Due for release in the spring, the new edition of the ATLS course will feature updated core content, interactive discussions, and structural changes to the skills stations.
A push to complete the national trauma system, a component of the NASEM report, is another priority for the COT, especially considering that at least one-third of Americans today reside in an area without a complete trauma system. “Now is the time to fill in the patchwork quilt of the national trauma system,” Dr. Stewart said. “We must implement a National Trauma Action Plan now, and quite frankly, we need your leadership [to do this],” he said.
He described the pillars of a modern trauma system—prevention, acute care, rehabilitation, a framework for disaster preparedness—and he noted that these pillars will be fully realized through teamwork and the leadership provided by the incoming Chair of the ACS COT, Eileen Metzger Bulger, MD, FACS.
In addition, Dr. Stewart described the “two contrasting narratives” regarding firearm injury prevention. In a 32-question survey completed by U.S. COT members in February 2016, slightly more than half of surgeons surveyed adhere to one narrative that considers firearms important for safety and are emblematic of personal liberty. In contrast, approximately 30 percent of surgeons surveyed subscribe to the second narrative that firearms place citizens at risk for harm and reduce personal liberty. He called for stakeholders to approach firearm injury prevention as a public health issue and to engage in “consensus decision making centered around doing the right thing for the patient and our citizens.”
ACS military partnership
David B. Hoyt, MD, FACS, Executive Director of the College, described the Military Health Service Strategic Partnership American College of Surgeons (MHSSPACS), which launched in December 2014, as the most recent example of a long tradition of the military and civilian surgeons working together to improve patient care. As examples of the contributions of ACS members, Dr. Hoyt noted that COL Edward D. Churchill, MD, FACS, Theater Commander for Surgery in the Mediterranean in World War II, challenged military brass to treat hemorrhagic shock with blood rather than plasma, and that Paul Hawley, MD, FACS(Hon), Past-Director of the ACS, has been credited with developing the U.S. Department of Veterans Affairs’ health care system.
“Vietnam is when we started to really change things, from a trauma standpoint, because of the availability of helicopters,” added Dr. Hoyt. “Patients were now transported to where physicians could do something,” he said, underscoring the importance of rapid evacuation to definitive care.
After describing these historic accomplishments in trauma care, Dr. Hoyt focused on the future of civilian and military surgical collaboration specifically related to military health system (MHS) readiness.
Citing a study of 86 military-affiliated surgeons conducted by C. William Schwab, MD, FACS, FRCS, Dr. Hoyt noted that more than 50 percent had two years or less of independent surgical practice for their first deployment. Almost 25 percent were stationed without another general surgeon present, and 60 percent found their pre-deployment military training unhelpful.
“And, so, what happens when peace breaks out?” asked Dr. Hoyt, referring to surgeons who deploy on missions with little surgical activity. “Many with combat experience separate from the service, and others return to a garrison practice with little trauma exposure. Currently, of the 57 military treatment facilities, only seven see trauma, and only one is verified by the ACS Committee on Trauma as a Level I center.”
To enhance MHS readiness, Dr. Hoyt and Jonathan Woodson, MD, FACS, then-Assistant Secretary of Defense for Health Affairs, signed a memorandum of understanding in October 2014 that focused on education and training for military surgeons, quality initiatives, systems-based practice related to the military trauma system, and trauma research.
“We brought together 12 surgeon subject matter experts (SMEs) who had seen deployment and had experience in surgical education,” Dr. Hoyt said, referring to steps taken to execute the education and training component of the agreement. The SMEs, representing the Army, Navy, and Air Force, compiled a list of topics based on the Joint Trauma System Clinical Practice Guidelines. The list was, in turn, distributed to nearly 700 surgeons with deployment experience to develop training course and assessment tools.
COL Brian J. Eastridge, MD, FACS, professor, department of surgery, division chief, trauma and emergency general surgery, University of Texas Health Science Center, San Antonio, underscored the importance of enhancing prehospital treatment of battlefield casualties to reduce case fatality rates and preventable deaths among U.S. servicemen and women. “We looked at combat deaths that were occurring before patients even reached the hospital, and 25 percent were found to likely have a survivable injury. A large majority, about 90 percent, died from hemorrhage,” Dr. Eastridge said, citing a published study that examined 4,596 battlefield fatalities between October 2001 and June 2011.
“Now that TCCC is broken up into phases of care, we’ve got better techniques and technology for hemorrhage control,” he said. TCCC phases of care include: (1) care under fire, (2) tactical field care, and (3) tactical evacuation care.
“While both the military and civilian sector have a high level of quality of care, they are not effectively integrated,” said Donald Jenkins, MD, FACS, professor of surgery, vice-chair, department of surgery, University of Texas Health Science Center, San Antonio, noting the NASEM report’s call to form a sustainable military/civilian workforce partnership. The cyclical nature of combat—times of war with lengthy periods of peace in between—is one challenge to maintaining a military trauma system, according to Dr. Jenkins, as is the lack of a discernable career path for military trauma leaders within the Department of Defense (DoD) health care system. Another barrier to developing a joint workforce centers on the fact “some military occupations do not have a civilian counterpart, and often credentialing and licensing are not transferable to the civilian setting,” he said.
One solution to these workforce-related challenges involves revamping entry-level training for the trauma workforce so that it is more uniform through the development of a standard curriculum and assessment to measure skills and abilities. Another solution, noted Dr. Jenkins, is to standardize data collection, particularly in the prehospital setting, by incorporating the DoD Trauma Registry and the National Trauma Data Bank, from the point of injury to rehabilitation.
The session concluded with a report from Dr. Hoyt, who provided an update on the Achieving Zero Preventable Deaths Conference that took place in April in Bethesda, MD. The conference, attended by 169 stakeholders (both physicians and nonphysicians) was designed to “disseminate, refine, and implement the NASEM report recommendations,” he said. College and COT initiatives based on the recommendations of the NASEM report and discussed at the conference include the development of minimum trauma system standards with the goal of creating a national trauma system and a partnership with the National Association of State Emergency Medical Services Officials (also known as NASEMSO) to develop a joint policy statement linking EMS and hospital data.
Essentials of teamwork for the trauma team
“There is a prevalent theory that says safety is achieved by doing the same thing, the same way, every time, and that safety can best be maintained by limiting variability,” said Andrew Grose, MD, assistant professor of orthopaedic surgery, Westchester Medical Center, Hawthorne, NY, and associate editor, Patient Safety in Surgery. “But in the clinical environment, everything is rapidly changing and evolving. There is no such thing as a routine, uneventful minute, hour, or day.” He noted that threat management and task adaptation skills—which are rooted in both technical acumen and communication-based competencies—are essential for achieving acceptable outcomes.
“We do everything we can to reduce variability in the airline industry,” added co-presenter Peter Caulk, a health care crew resource management expert and a former instructor for the U.S. Navy’s elite fighter weapons school, also known as Top Gun. “The impact of doing these things right is tremendous. In health care there is a certain pride if you operate self-deprived of sleep, but not in aviation,” Mr. Caulk said, citing a study published in the British Medical Journal in 2000 that examined 31,033 pilots and surgeons and their attitudes regarding error and teamwork in aviation and medicine. Of the pilots who responded to the study’s survey, 74 percent answered “yes” when asked if fatigue has a negative effect on performance, while 30 percent of surgeons, nurses, and residents responded “yes” to the same query, Mr. Caulk said.
Checklists are tools that help ensure safety and reduce errors in both aviation and medicine, but they only work if they are tethered to effective team communication. “You can have a checklist, but if the culture doesn’t support it, it doesn’t work,” said Mr. Caulk. The keys to bolstering team buy-in include exhibiting interpersonal skills; supporting participation by each team member; asking open-ended questions beyond the yes/no format; encouraging team briefings (setting goals and concerns); and standardizing the process.
Checklists only work if they are used 100 percent of the time, are interactive, developed by the users, easy to use, and can be shortened for emergencies when appropriate, Dr. Grose added.
Trauma survivor: Noah Galloway
During his second deployment in 2005, Noah Galloway was severely injured after a roadside bomb exploded while the U.S. Army soldier was driving along a remote road in southwest Bagdad. The bomb resulted in the loss of Mr. Galloway’s left arm below the elbow and his left leg above the knee. He woke up on Christmas Day at Walter Reed Hospital.
A period of deep depression set in. “I drank all the time and wasn’t taking care of myself. I was always into fitness, and I let that go. I rushed into a second marriage and when that didn’t work, I realized I was really struggling,” said Mr. Galloway, who would eventually place third on the 20th season of Dancing with the Stars in 2015. “People always ask me, ‘What is the one thing that turned it around?’ Life is not a movie—there isn’t one thing that happens and everything is fine,” he said. Mr. Galloway noted that his three children were his chief inspiration for overcoming his emotional and physical challenges.
Mr. Galloway eventually quit smoking and drinking, resumed his fitness regimen, and became the first veteran and amputee to be featured on the cover of Men’s Health magazine as the “Ultimate Men’s Health Guy.”
Mr. Galloway urged health care providers to guard against burnout and to make self-care a priority. “Make sure to take care of yourselves. We need you at your best, because you are saving our lives.”
The ninth annual TQIP Scientific meeting and Training will take place November 16–18, 2018, at the Anaheim Convention Center, CA.
The photos in this article were taken by Dr. Stewart.