Looking forward – June 2017

David B. Hoyt

David B. Hoyt, MD, FACS

In April, representatives from the National Academies of Sciences, Engineering, and Medicine (NASEM); the American College of Surgeons (ACS) Committee on Trauma (COT); the National Highway Traffic Safety Administration; and the Department of Defense convened at the National Institutes of Health campus in Bethesda, MD, for a conference titled Achieving Zero Preventable Deaths: Building a National Trauma Care System and Research Action Plan. This meeting took place as a follow-up to the report A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury, which NASEM released within the last year in collaboration with the ACS COT and other stakeholders.

As noted in the October 2016 issue of the Bulletin, last year’s NASEM report offers 11 specific recommendations on how to integrate the military and civilian trauma systems to ensure that all Americans—civilian and military—receive optimal trauma care.* The report envisions a national trauma care system and calls for a unified effort to ensure the delivery of optimal trauma care to save the lives of Americans injured on U.S. soil and on the battlefield. In particular, the report calls for a national learning trauma care system that would ensure continuous improvement of trauma care best practices in military and civilian sectors.

Participants in the Achieving Zero Preventable Deaths conference. Front row, from left: Timothy C. Fabian, MD, FACS; Michael F. Rotondo, MD, FACS, Medical Director, ACS Trauma Programs; Dr. Stewart; Dr. Winchell; Dr. Nathens; Dr. Bulger; and Donald H. Jenkins, MD, FACS.

Participants in the Achieving Zero Preventable Deaths conference. Front row, from left: Timothy C. Fabian, MD, FACS; Michael F. Rotondo, MD, FACS, Medical Director, ACS Trauma Programs; Dr. Stewart; Dr. Winchell; Dr. Nathens; Dr. Bulger; and Jerry Jurkovich, MD, FACS.

One step up…

The 2016 report was, in many ways, a status update on a 1966 report from the National Research Council, Accidental Death and Disability: The Neglected Disease of Modern Society, which called for increased federal and voluntary financial support of basic and applied research in trauma and expansion of U.S. Public Health Service research in shock, trauma, and emergency medical conditions. Since the issuance of the 1966 paper, much progress has been made, including major reductions in mortality and complications, the establishment of professional disciplines centered on trauma care, advancements in research and data systems, and development of educational and training programs centered on trauma care.

Dr. Fabian (left) and Dr. Jenkins

Dr. Fabian (left) and Dr. Jurkovich

Nonetheless, the U.S. trauma system remains a patchwork quilt with access gaps in some areas of the country. As a result, more than 130,000 Americans die from traumatic injury every year, and trauma is the leading cause of death among children and uniformed service personnel. Traumatic injury results in more lost years of life and disability than any other disease, yet trauma research receives significantly less funding than human immunodeficiency virus, cancer, heart disease, and other health care conditions.

This year’s conference

The purpose of this year’s conference was largely to begin laying out strategies for implementation of the 2016 report’s recommendations and to fill the lingering gaps in trauma care, which are highlighted in previous reports published in 1985, 1994, 1999, and 2006. A multidisciplinary group of attendees, including military and civilian trauma physicians and nurses, prehospital professionals, public health professionals, government representatives, and NASEM staff and leadership, sought to analyze the current global clinical and patient access barriers facing all trauma systems with the goal of achieving zero preventable trauma deaths by ensuring that patients receive expert trauma care quickly.

ACS COT Chair Ronald Stewart, MD, FACS; Donald Berwick, MD, MPP, FRCP, president emeritus and senior fellow, Institute for Healthcare Improvement, and former Administrator, Centers for Medicare & Medicaid Services, speaking via teleconference; and I offered welcoming remarks at the April conference, emphasizing the importance of collaborative efforts to improve trauma care. Robert Winchell, MD, FACS, a longtime member of the COT, did much to lead the development of the meeting program, which included many sessions and consensus discussions.

Pathways forward

Dr. Bulger (foreground) and Dr. Winchell

Dr. Bulger (foreground) and Dr. Winchell

A number of new recommendations for achieving zero preventable deaths emerged from the meeting. Eileen Metzger Bulger, MD, FACS, a member of the COT Executive Committee, led a session on research funding and direction. Session participants agreed that to achieve zero preventable deaths in trauma, we need to develop a well-defined research agenda and priorities to support advocacy efforts. The trauma community will need to tear down the internal silos of “bone, blood, burn, brain” and speak with a united voice to advocate for a national trauma research action plan and engage the public and trauma survivors in these efforts as well.

We also need to rethink the trauma center verification process. At present, hospitals may self-select for approval as Levels I or II trauma centers based on financial incentives, rather than demonstrated need in their region. Furthermore, the present system is time-consuming, expensive, and labor-intensive, both for COT surveyors and for trauma centers. Meeting participants suggested moving to outcomes-based verification using the quality measurement model centered on structure (staff, physical resources, policies); process (whether medicine was practiced properly); and outcome.

Therese West, DNP, makes a point from the audience

Therese West, DNP, makes a point from the audience

Meeting participants also agreed that trauma professionals need to do a better job of collecting and analyzing trauma care data. The importance of data was heavily emphasized in a session led by Avery B. Nathens, MD, PhD, FACS, FRCSC, another COT leader and Medical Director, ACS Trauma Quality Programs. Participants examined impediments to data linkage across the continuum of trauma care. Suggestions regarding how to overcome these barriers, including use of uniform trauma identification bands, were offered. Speakers examined evidence-based information and suggested strategies for establishing a national trauma system that incorporates clinical outcomes to reduce preventable injury and disability in the trauma patient population. We discussed methods for linking data and transitioning patients between facilities, as well as the development of a methodology to track trauma patients from injury to post-discharge.

Speakers suggested the development of a National Trauma Action Plan, which would articulate a unified research agenda across the continuum of care, define the “ask” for financial investment, set a strategy for establishing a federal home for trauma research funding, develop strategies to address regulatory burden, and offer a unified approach to advocacy.

A unified system

USAF Colonel Jeff Bailey, MD, FACS, MHSSPACS Systems Co-Chair and Director for Surgery, Walter Reed National Military Medical Center; and professor, Uniformed Services University Walter Reed Department of Surgery

USAF Colonel Jeff Bailey, MD, FACS, MHSSPACS Systems Co-Chair and Director for Surgery, Walter Reed National Military Medical Center; and professor, Uniformed Services University Walter Reed Department of Surgery

A key focus of the conference was the integration of the military and civilian trauma workforce. At present, lessons learned on the battlefield are not reliably translated to civilian care. Part of the problem is the military health system has a shortage of dedicated trauma surgeons. To unify the civilian and military trauma systems, the military health services and the College have created the Military Health System Strategic Partnership American College of Surgeons (MHSSPACS). Through the MHSSPACS, we already are taking important steps to achieve the NASEM report’s goals, as M. Margaret “Peggy” Knudson, MD, FACS, Medical Director, MHSSPACS, noted at the meeting.

Furthermore, the U.S. Congress is expected to vote on the Mission Zero Act (H.R. 880) this year. The bill would provide $40 million in funding to the U.S. Department of Health and Human Services to facilitate partnerships between military trauma care teams/providers and high-volume civilian Level I trauma facilities. Passing the Mission Zero Act will allow us to take these initiatives further by partnering civilian and military surgeons and care teams at some of the busiest trauma centers in the nation.

As a trauma surgeon and COT member for many years, I have firsthand experience with the evolution of trauma surgery in the U.S. I have seen it evolve into a dedicated specialty composed of some of the most skilled and compassionate surgeons in the profession. Nonetheless, much work needs to be done. Efforts like the ones described in this column and at the meeting in April will go a long way toward ensuring that trauma patients on and off the battlefield receive optimal care.

*Hoyt DB. Looking forward. Bull Am Coll Surg. 2016;101(10):8-9.


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