TQIP 2020 meeting outlines the future of trauma care

The American College of Surgeons (ACS) hosted the virtual 2020 Trauma Quality Improvement Program (TQIP®) Annual Scientific Meeting and Training December 7−10. Drawing 6,453 participants as of mid-December—including trauma medical directors, program managers, coordinators, performance improvement (PI) clinicians, and registrars from participating and prospective TQIP hospitals and trauma professionals around the globe—the conference commemorated TQIP’s 10th anniversary.

Other highlights included sessions on the following topics:

  • A guest speaker’s call to action for reducing the stigma of post-traumatic stress disorder (PTSD) among first responders and trauma care professionals
  • An overview of key topics in trauma in the next 10 years, including virtual verification site visits, the TQIP coaching project, and patient-reported outcome measures (PROMS)
  • Best practices guidelines for acute pain management
  • Strategies for leading during a time of crisis

All sessions were available for on-demand viewing to registrants February 10. This article highlights several popular sessions presented at the TQIP conference.

GS01: Opening Session

Avery Nathens, MD, PhD, FACS, FRCSC, Medical Director, ACS Trauma Quality Programs, provided an overview of TQIP milestones since the program’s inception in 2010. “Just like we’ve shown leadership and commitment over the course of the pandemic, when I think about where we were 10 years ago with TQIP, I am amazed at the leadership and commitment that all of you have shown in helping us advance the care of the injured patient,” Dr. Nathens said.

TQIP evolved from a pilot of 22 centers to 60 centers in its first year, to now 860 hospitals across the U.S. and Canada, all committed to offering care to trauma patients. Dr. Nathens underscored the following six domains of quality:

  • Safety (avoiding harm)
  • Effectiveness based on evidence
  • Patient-centeredness
  • Timeliness
  • Efficiency
  • Equity

He discussed other TQIP initiatives from the last decade, including the development of TQIP collaboratives, TQIP/ Performance Improvement and Patient Safety Best Practice Guidelines for Trauma Care, and the TQIP Mortality Reporting System.

More recent developments, Dr. Nathens noted, include the move toward virtual site visits in the COVID-19 era; updates to standards, best practices, and research; and modifications to the TQIP report.

GS02: Special Guest Speaker Dan Sundahl

Dan Sundahl, a Canadian advanced care paramedic, firefighter, and photographer from Leduc, AB, shared his artwork with attendees and described how his creative process helped him build resilience and cope with PTSD. The session provided strategies for recognizing the signs and symptoms of mental and emotional stress, offered practical approaches for enhancing resilience, and described ongoing research in treating PTSD.

After suffering from mental distress, which he did not initially associate with work-related trauma, Mr. Sundahl was diagnosed with PTSD. “I thought you have this event, and then you have PTSD. For me, I didn’t have that one event that affected me that way. In my case, it was a long series of events that eventually impaired me,” Mr. Sundahl said. “Part of my treatment is to create artwork that helps me process some of these feelings. By doing that, I purge these emotions out of my mind and capture them in the artwork.”

Some of the symptoms Mr. Sundahl experienced include difficulty sleeping, overwhelming feelings of apathy, overeating, irritability, diminished confidence, crying for no apparent reason, and feelings of general anxiety. “I would hear sirens or things that sounded like my radio, and I would feel overwhelmed with anxiety, whereas before, as a newer paramedic, I would get excited by those sounds,” he said.

His distress led Mr. Sundahl to start having thoughts about his mortality. “They weren’t suicidal thoughts, but thoughts, like, ‘If I died in a house fire today that would be okay. If I died at work that would be okay because my family would be taken care of.’ That is pretty scary thinking about it now. I thought that was a normal thought process,” he said.

“The first art piece that I did was based on the trauma of a man who was hit on a motorbike by a drunk driver and died in the back of our ambulance. When he died, he was calling for his mother. He kind of regressed to this little boy, and he was saying, ‘Mommy, Mommy, Mommy,’ and that really stuck with me—that his mom was never going to know that he died this way. I never intended to share this picture with anybody. If you look at it, there’s a paramedic with gloved hands on their head. And my thought was, ‘If I shared this picture, I’m going to get crucified by the 30 friends I have on Facebook, because I am showing a paramedic that is being sad and is vulnerable’” (see images).

‘Trauma Code 1 and 2,’ the first images Mr. Sundahl made using his experience as motivation. DanSun Photo Art, www.dansunphotos.com.

Mr. Sundahl eventually decided to follow his impulse and share the painting—and he went from having 30 friends on Facebook to 30,000 in one day. “It struck a chord with a lot of people,” he said.

“Often, when we think about PTSD, our goal is to recover in order to get back to where we were,” added Mr. Sundahl. “But the reality is, if we can do the work, we can actually rise to a higher level than what we were before.”

He outlined common traits of resiliency including fostering optimism, developing a moral compass, locating resilient role models, and improving cognitive flexibility.

“I’m not a mental health professional. I am just sharing my own experiences, which I know are very common among my community in emergency services,” he said.

During a post-session Fireside Chat with Dr. Nathens, Mr. Sundahl described best approaches for asking for help with mental and emotional stress and underscored the importance of raising awareness about the symptoms associated with PTSD.

GS08: Keynote Address: Leadership Through Crisis

Michael G. Barger, EdD, co-founder of JetBlue Airways and the executive director of Ross Online at the Stephen M. Ross School of Business, University of Michigan, Ann Arbor, delivered the keynote address, which focused on helping leaders harness the collective intelligence and skills of their teams to succeed when faced with challenging events.

After graduating from the University of Michigan in 1986, Dr. Barger served as an officer in the U.S. Navy with a focus on pilot education, highlighted by a tour as a student, instructor, and then chief instructor at the Navy Fighter Weapons School (also known as TOPGUN).

“I had the honor and privilege of leading the TOPGUN school for a couple of years. It’s nothing like the movie, but it’s a spectacular place to learn about critical decision-making in high-pressure situations,” Dr. Barger said. “Leaving the Navy after 13 years, a group of colleagues and I started JetBlue Airways—[which] might not be as cool as being a fighter pilot, but it is still pretty exciting in terms of seeing the intersection of learning and doing. I ran operations and our corporate university, so I got to see that intersection and learn a lot about how training can help people prepare for the inevitable crises that their organizations will have to work through,” he said.

Dr. Barger outlined the concept of “volatile, uncertain, complex, and ambiguous” (VUCA), which originated with U.S. Army leadership in the 1980s to describe the evolving battle space of the future. He said that these “four elements make it more challenging for troops to deal with the situations they lean in to” and that the VUCA concept applies to the business environment of today.

“In our VUCA world, we know that things are going to go sideways. Whether they go sideways in an instant or sideways over a longer period of time, the reality is when things do go sideways, the importance of leadership becomes really clear,” Dr. Barger said. “And these are the times when leaders must be willing and able to step up and lead.”

Dr. Barger defined a crisis as “an unstable or crucial time or state of affairs in which a decisive change is impending; especially one with the distinct possibility of a highly undesirable outcome.”

He said that in times of crisis stakeholders do not expect leaders to be perfect or omniscient, but they do expect them to be “visible, courageous, and committed to the best path forward.” At the same time, effective leaders should recognize that each group of stakeholders is going to have its own set of concerns.

“As a crisis leader, our goal is not only to resolve the crisis, but it is to remember that the entire purpose of our organization is to serve these stakeholders, not just today but into the future,” Dr. Barger said.

“The very nature of the crisis environment, such as COVID-19, creates a seemingly impossible situation for high-stakes leaders,” he said. “Being a high-stakes leader will require you to face these realities, embrace vulnerability, and lead knowing that your decisions will never be perfect,” he added.

“Being a high-stakes leader will require you to face these realities, embrace vulnerability, and lead knowing that your decisions will never be perfect.”
—Keynote Speaker Michael G. Barger, EdD

John P. Hunt, MD, MPH, FACS, Louisiana State University Health Sciences Center, New Orleans, moderated the fireside chat after the keynote address. The focus of this discussion was on planning for mass casualty events at the trauma center and system levels and tactics for disseminating the correct message and facts to an organization’s stakeholders during a crisis.

GS03: Trauma—The Next 10 Years

This session focused on three hot topics in trauma that will take center stage in the next decade, including virtual site visits, the TQIP coaching project, and PROMs—and an overview of where trauma care and training are headed in the next decade.

Daniel R. Margulies, MD, FACS, Cedars-Sinai Medical Center, Los Angeles, CA, moderated the presentation on virtual site visits. During the pandemic, “We’ve done virtual site visits with all the ACS verification programs, and it has been, quite frankly, wildly successful,” said David B. Hoyt, MD, FACS, ACS Executive Director. “Virtual site visits are better than a regular site visit in some regards. There is certainly a convenience factor, and they give the hospital a chance to prepare in sort of the same way.”

Chart reviews and facility tours are some of the challenges associated with virtual site visits, Dr. Hoyt noted, adding that, over time, administrators will settle on best practices for these challenges and other aspects of virtual site visits.

Chart reviews and facility tours are some of the challenges associated with virtual site visits, Dr. Hoyt noted, adding that, over time, administrators will settle on best practices for these challenges and other aspects of virtual site visits.

“I think the really interesting thing is that we thought we would do this for a couple of months and then go back [to in-person site reviews], but I don’t think it is going to go back the same way, just like education and so many other things we’ve experienced,” Dr. Hoyt said, noting that specific circumstances may warrant physical site visits in the future.

Michael Chang, MD, FACS, Chair, Trauma Quality Programs Pillar and Chair, TQIP Subcommittee for the Committee on Trauma, focused on analyzing TQIP data to identify coaching partners for medical centers engaging in PI projects. The TQIP Coaching Program is being developed by Robbie Dumond, RN, UC Health University of Colorado Hospital, Aurora, and Heidi Hotz, BSN, RN, Cedars-Sinai Medical Center.

“With the TQIP program, there really is this mission-driven desire to connect centers that are maybe not performing well with centers that are performing well,” Ms. Dumond said.

“The TQIP Coaching Program is not exclusive, but it is not for the entry-level program manager,” Ms. Hotz said. “This coaching program is for people who have been in it up to their eyeballs and already have a strong grasp on what to do when they get a TQIP report. This program is more for the intermediate or advanced user.”

The TQIP Coaching Program is in the process of establishing best practices for centers to apply to participate in the initiative.

The next presentation, moderated by Angela Ingraham, MD, MS, FACS, University of Wisconsin-Madison, outlined the role of PROMs in trauma patient care and the opportunities and challenges associated with collecting this data.

“In trauma, we have focused on what happens over the course of the acute care admission,” said Dr. Nathens. “Ninety-three percent of those patients survive, and some of those patients have inhospital complications. But after they leave the hospital, we know that 25 percent have PTSD, maybe half don’t return to work in the first year, and that many have chronic pain—and we have no insights for who is at risk for those problems. These are the outcomes that matter to patients.”

Dr. Nathens outlined three measures that will allow clinicians to understand how the patient is faring after discharge: EQ-5D, which determines the patient’s ability to provide self-care; PROMIS Ability to Participate, which determines the patient’s ability to fulfill professional and personal responsibilities; and the Care Transition Measure (also known as CTM-3), which determines how well patients are prepared to transition from the inpatient to the outpatient setting.

Dr. Nathens emphasized the need for a platform that will collect data for these measures. Plans are being developed for a portal that will reach out to patients via an automatic text or e-mail at specific intervals—one month, six months, and 12 months—with a self-assessment survey. Next steps also include locating centers that will participate in piloting and refining the platform.

The final presentation, moderated by Dr. Chang, provided a broad perspective on the future of trauma based on the insights of ACS President J. Wayne Meredith, MD, FACS, MCCM. “I think we will have opportunities in the future to show the value of having an organized system of emergency care, trauma, and acute care surgery—and that these patients do better and cost less to take good care of by getting that right patient, at the right place, and at the right time.”

GS04: TQIP Academy 101

The TQIP Academy sessions showcase real-world examples of how centers have used their TQIP benchmark report to identify opportunities for improvement and describes PI projects designed to address those issues. TQIP Academy 101 centers were selected to participate in this session because they were high outliers for a specific cohort or outcome and improved their status over time. TQIP Academy 201 centers were chosen because they moved from average performers to high performers for a specific patient cohort or outcome; and TQIP Academy 301 centers were those that have maintained excellence and have been consistently low outliers across multiple report cycles. TQIP Academy 101 featured the two following centers.

Dominick J. Eboli, MD, FACS, trauma director, outlined three areas for improvement—patient care, geriatric care, and pulmonary care—at Capital Health Regional Medical Center, Trenton, NJ, a 168-bed, Level II ACS Trauma Center. Improvements related to patient care were initiated by acquiring administrative buy-in to increase staff and by restructuring the intensive care unit. Modifying triage criteria for patients 65 years and older and other process improvements led to better geriatric patient care.

For the pulmonary care objective, administrators implemented an early mobilization protocol (EMP)—a form of rehabilitation that engages critically ill patients in activity that assists in their own recovery. “The benefits of EMP include accelerated recovery, decreased complications, greater long-term wellness, and an increased chance of returning to previous level of function,” he said.

“We were able to get all of our risk-adjusted major complications by cohort close to the top decile,” Dr. Eboli said, outlining the results of the PI initiatives at his center. “The only one where we failed to do this was isolated hip fractures. We did not admit all of them, so we did not control that.”

He recommended that attendees review their TQIP data, identify areas for improvement, develop an action plan that best fits the institution, follow TQIP best practice guidelines, and facilitate institutional buy-in.

“When we looked at the TQIP report and the areas we needed to focus on regarding major complications, we looked at acute kidney injury, CLABSI [central line-associated bloodstream infection], pressure ulcer, severe sepsis, and ventilator-associated pneumonia,” said Kim Windsor, RN, trauma program manager, Sutter Health Eden Medical Center, a 130-bed Level II trauma center in Castro Valley, CA.

The trauma center’s TQIP report for spring 2019 showed two cohorts of patients likely to experience complications—those with traumatic brain injury and geriatric patients. “Both were the cohorts we wanted to focus on, and in spring 2020 we did bring those complication numbers down pretty nicely,” said Ms. Windsor.

GS05: Best Practices Guideline for Acute Pain Management in Trauma Patients

The new Best Practices Guideline for Acute Pain Management in Trauma Patients, which debuted at the TQIP 2020 meeting, addresses the physiology, assessment, and multimodal treatment of pain across the continuum of care. “The intent of this guideline is to provide an evidence-based, practical guide to acute pain management in the trauma patient—from prehospital to discharge,” said Christine S. Cocanour, MD, FCCM, FACS, University of California Davis. “The ultimate goal is not achieving zero pain but making pain tolerable to allow activity.”

Andrew C. Bernard, MD, FACS, University of Kentucky, Lexington, gave an overview of pain management across the continuum of care, and Douglas Oyler, PharmD, University of Kentucky, described components of the guideline that address pain physiology, assessment, and multimodal therapy. Mr. Oyler underscored the importance of selecting the appropriate assessment tool; using multimodal analgesia, including pharmacologic, regional, and nonpharmacologic strategies in a systematic fashion; counseling patients on expectations (tolerability and function versus completely eliminating pain); and deescalating analgesics as quickly as possible.

Jorie D. Klein, MSN, MHA, BSN, RN, Texas Department of State Health Services, Austin, discussed best practices for integrating the pain management guidelines into the Trauma Performance Improvement Patient Safety Plan to monitor compliance, patient outcomes, and recommendations for documentation. Ms. Klein emphasized the importance of standardizing pain documentation to foster continuity of care and noted that discharge planning should include prescription drug monitoring program measures to ensure that regulatory and patient safety initiatives are fully addressed.

GS07: New Approach to Verification

This session provided program updates on ACS Verification, including the revised standards in the Resources for Optimal Care of the Injured Patient manual, results from the virtual visit pilots, and incorporating TQIP into the Trauma Verification and Review Committee (VRC) visit.

“The goal [in revising the standards] is to advance the optimal care of injured patients by updating the standards to ensure utility, relevance, and effectiveness; increase clarity and incorporate stakeholder feedback; and align with the ACS accreditation/verification processes,” Dr. Margulies said.

Revising the standards was an inclusive process, with more than 2,000 stakeholder comments from trauma centers and state emergency medical services agencies responding to the ACS’ call for feedback. The previous version of the Resources for Optimal Care of the Injured Patient manual featured 387 standards, and the updated version will include an estimated 141 standards, with some of the previous standards combined or eliminated. Often referred to in the past as the Orange Book, the new version of the manual will feature a charcoal-gray cover in the same style as the other quality manuals produced by the College, it will no longer be referred to by a color, and future versions will be referred to by year. The content will be divided into nine categories to align with other ACS Quality Program standards.

Nilda M. Garcia, MD, FACS, Dell Children’s Hospital/Dell Medical School, Austin, TX, described lessons learned from the VRC virtual pilot. Three U.S. centers were selected for the first phase of VRC verification, including an Adult Level I center, a Pediatric Level I center, and an Adult Level III center. Dr. Garcia outlined the following five takeaways from the VRC virtual verification pilot:

  • A site visit coordinator, who should not be the trauma program manager or trauma medical director, is essential to ensure the smooth functioning of all electronic aspects of the site visit (video calls, chart access, tour, and so on).
  • A prereview call is vital to ensure that the reviewers have access to all the materials they need and to answer any questions the site may have prior to the visit.
  • The preselected chart process is key because it allows for time savings for the hospital and the ability for the reviewer to review charts ahead of the site visit.
  • All requested program documents must be provided to the reviewers before the visit in a Health Insurance Portability and Accountability Act-compliant format.
  • The site visit agenda should be revised to support the virtual process while allowing as much interpersonal interaction as possible.

Dr. Nathens outlined the role of TQIP in the VRC virtual visit. Since 2015, TQIP primers have provided an overview of the TQIP benchmark report, center-specific performance, and guidance on how the center could use the results to improve data quality and patient care.

Since 2015, TQIP primers have provided an overview of the TQIP benchmark report, center-specific performance, and guidance on how the center could use the results to improve data quality and patient care.

“The new approach will include scheduled time in the site visit agenda that will be committed to reviewing the TQIP report,” he said. The scheduled 30-minute discussion will center on areas for improvement and the center’s specific efforts (data drill down, PI projects, and so on) to address any issues.

The rollout will start in early 2021, according to Dr. Nathens. Centers are expected to present on internal PI projects they have implemented as a result of their TQIP report.

The 12th annual TQIP Scientific Meeting and Training is scheduled to take place November 14−16, in Denver, CO.

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