January 10, 2024
The 2023 Trauma Quality Improvement Program (TQIP) Annual Conference, which took place December 1–3 in Louisville, Kentucky, featured educational programming tethered to the meeting’s theme—Road to Recovery—and included presentations describing clinical best practices, the value of the ACS Quality Program, and a powerful story of trauma survivorship.
The conference drew 1,916 in-person and 387 on-demand registrants. On-demand registration remains open through April 3, 2024.
“We know there are significant benefits to being cared for in a trauma center,” said Avery B. Nathens, MD, PhD, MPH, FACS, FRCSC, Medical Director of ACS Trauma Quality Programs. He cited a study published in The New England Journal of Medicine that found patients cared for in a trauma center have a 20% lower mortality rate and a better quality of life. (The study, published in 2006, was coauthored by TQIP keynote speaker Ellen J. MacKenzie, PhD.)
Trauma center care, while cost effective, also is expensive. Outlining the costs associated with trauma center preparedness (including program leadership/support, clinical medical staff, education/outreach, and in-house OR availability), Dr. Nathens suggested that trauma activation fees represent part of the solution. Costs also can be offset by providing high-value care driven by benchmarking reports, conducting effective quality improvement initiatives, and by ensuring high-quality documentation that reflects case complexity.
After discussing the benefits and costs associated with trauma care, Dr. Nathens provided an update on key TQIP initiatives such as the new Verification, Review, and Consultation Program standards, which were implemented September 1, 2023, with 67 site visits as of November 15.
“We don’t intend to go back to every site visit being conducted in person…and the perceptions of value of virtual versus in-person visits are variable. I think a reasonable compromise is that if we’re seeing your center for the first time then there’s a significant chance it will be an in-person site visit,” he said.
Dr. Nathens also provided updates regarding the program’s renewed focus on rural trauma; the statuses of the Patient Reported Outcomes pilot and the TQIP Mortality Reporting System; and changes to the ACS TQIP Benchmark Report expected this spring.
Dr. Patricia Turner
Dr. Avery Nathens
The Executive Session—part of the new Executive Track developed with hospital quality thought leaders in mind—highlighted the value of ACS Quality Programs, including the trauma center verification program, and provided insights on The Power of Quality Campaign presented by ACS Executive Director and CEO Patricia L. Turner, MD, MBA, FACS.
“There are more than 1,200 hospitals participating in our Quality Programs that are already displaying the ACS Surgical Quality Partner diamond plaques,” said Dr. Turner. “By October 2024, we aim to have the diamond in 2,500 US hospitals.”
There are four primary stakeholders connected to the Quality Campaign: patients, surgeons, hospital systems, and payers and policymakers.
“Quality is not an act, it is a habit,” said Dr. Turner, quoting Aristotle. “This is something that all of you do. You are, in many ways, our best ambassadors.”
Clifford Y. Ko, MD, MS, MSHS, FACS, Director of the ACS Division of Research and Optimal Patient Care, compared the value of ACS and Vizient in terms of measuring outcomes. “I can’t say wholeheartedly that one is better than the other. Both organizations seek to improve care, outcomes, and value. Some aspects overlap and some are unique. To achieve data validity, completeness, and feasibility—a combination of ACS and Vizient data might be ideal—and early discussions are underway.”
“TQIP standards will continue to support the structure and processes that are fundamental to achieving quality, while also supporting reliability,” he said. “The ability to evaluate, surveil, and benchmark [performance] will advance as technology, such as automation and artificial intelligence, continues to advance.”
The next presentation described the “halo effect” of trauma centers on the hospital’s overall quality improvement initiatives. “The presence of a Committee on Trauma (COT)-verified trauma center hardwires a culture of high reliability across the entire hospital,” said Michael Chang, MD, FACS, system chief medical officer and associate vice president for medical affairs at USA Health in Mobile, Alabama.
Dr. Chang noted that this influential halo effect is driven by the 109 distinct standards outlined in the Resources for Optimal Care of the Injured Patient manual. Each standard is organized into nine domains, including patient care expectations/protocols, data surveillance, research, and others. Adherence to these standards means that performance and processes are consistent from center to center, and this uniformity helps achieve better outcomes.
“The maturity of the COT verification program has led to an extraordinary opportunity for hospitals in the quality space. It is our obligation as trauma leaders to own this opportunity and ensure that our hospital and health system leaders understand what our trauma programs have to offer,” he said.
Deb Brown, RN, BSN, MHA, vice-president and chief operating office of Dell Children’s Medical Center in Austin, Texas, outlined strategies for securing C-suite support for the trauma program. “Why do we invest in trauma? It’s really about the patients, and at the end of the day, you know that [these programs] provide improved outcomes with organized, high-quality, effective, and efficient care,” explained Brown.
Trauma care also enhances a hospital’s reputation, which can result in support and resources at the local, state, and national levels. “We’re taking care of the most vulnerable patients in our communities…We get to publicize our outcomes and what we’re doing with patient families,” she said, noting that promoting trauma care and injury prevention is “like mom and apple pie.”
Obtaining resources for a trauma center should be based on a 3-year strategic plan with quarterly reviews that examine market share, staffing, equipment, and programs. Fostering 100% engagement with surgeon leaders is the “secret sauce” to achieving buy-in, she said, primarily by educating hospital administrators on ACS and state standards and best practices, and by describing to them what other successful organizations are doing.
Come prepared when making a request to administrators, advises Brown. Be aware of the current state of affairs; provide background (history and data); and make a recommendation that includes financial implications, describing the return on investment—which might not be monetary.
“We learned something about family and bonds. These are my people. We are a trauma family. I want you all to build that family at you center as well because that is when you get these outcomes.”
Illustrating the collaborative nature of the entire trauma care team, this year’s Trauma Survivor session featured Tate and his mother Nicole Reynolds, who shared the story of Tate’s remarkable recovery after leaping over the back of a couch and landing on a misplaced steak knife. Tate, 11 years old at the time (2017), coded three times—his aorta sliced in half, his kidney lacerated, and the knife lodged into his spine.
Anne G. Rizzo, MD, FACS, the system surgical chair at Guthrie Clinic in Sayre, Pennsylvania, was Tate’s attending surgeon at Inova Fairfax Hospital in Falls Church, Virginia. Dr. Rizzo moderated the session and shared her perspective as a trauma care provider.
Dr. Rizzo described trauma surgery as “the ultimate puzzle” that requires all the pieces to work together correctly: “It was just about at shift change. We had the crew that was basically getting ready to go home—they stayed. The new crew came in, and they assisted as well so we actually had two crews of people working for hours to keep this boy alive.”
“When Tate came in and I looked at his initial x-ray as we were rushing him to the operating room, I thought ‘Oh my god, I don’t know that I can save this boy,’ because that knife was in the center of his ability to live,” said Dr. Rizzo in a video developed by the Inova Health Foundation and presented during the session.
Despite the severity of his injuries, Tate is alive today due to the excellent care he received from Dr. Rizzo and the entire trauma care team. “We learned something about family and bonds,” Dr. Rizzo said. “These are my people. We are a trauma family. I want you all to build that family at your center as well because that is when you get these outcomes.”
In the 2023 TQIP Keynote Address, Dr. MacKenzie, dean and Bloomberg Distinguished Professor at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, described the impact of individual and environmental factors on the recovery process for trauma survivors.
“TQIP has played an important role in assessing the data for risk-adjusted benchmarking and so much more,” Dr. MacKenzie said. “Your efforts as stewards of the National Trauma Data Bank®, your local registries, as well as TQIP are no small measure responsible for the major advances we’ve seen in the quality of trauma care and its impact on trauma case fatality and morbidity.”
Unfortunately, routine data collection ends once the patient is discharged by the trauma center, which is a missed opportunity for identifying areas for systemic improvement.
Dr. MacKenzie cited the landmark report A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury, which called for existing trauma registries to develop mechanisms for incorporating long-term outcomes (e.g., patient-centered functional outcomes, mortality data at 1 year, and cost data).
She highlighted the evolving recognition of patient-reported outcomes, which she said provided an “important perspective of treatment and efficacy and complements what is captured by what many clinicians would view as more objective measures such clinical assessments.”
Dr. MacKenzie also outlined the psychosocial and mental health sequalae of physical trauma, noting that psychological distress following trauma is common, and while most patients do not meet the diagnostic criteria for major disorders, even moderately elevated levels lead to poor outcomes.
Resources such as the ACS Trauma Quality Programs (TQP) Best Practices Guidelines for Screening and Intervention for Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient are recommended to aid in the recovery process for trauma survivors.
“This is a great source of information on screening. It reviews several brief screening tools that have been validated specifically for hospitalized trauma patients, both adults and children,” she said. “And while some questions remain regarding who should do the screening, when it should be done…we do have a set of tools that we can fall back on and deploy.”
“The annual national inpatient trauma costs are estimated to be $30,741,846,525,” said session moderator Andrew Bernard, MD, FACS, trauma medical director at the University of Kentucky in Lexington, citing a study published in the Journal of Surgical Research.
In this session, panelists outlined potential trauma center revenue streams and strategies for reducing costs. “Cost analysis and economic evaluation are critical to allow hospital to remain open and to continue to provide care,” said Dr. Bernard.
R. Shanyn Martin, MD, MBA, FACS, professor of surgery at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina, described three sources that generate revenue for trauma centers: diagnosis-related groups (DRGs)—a system that groups patients with similar diagnoses together and associates the type of patients a hospital manages to the cost of care; Case Mix Index (which includes DRG weights for all cases); and professional billing (driven by Current Procedural Terminology codes, and is predominately fee-for-service).
After highlighting potential sources of revenue, Dr. Martin addressed key costing methodologies, including micro-costing, time-driven/activity-based costing, gross costing, and expenditure-based costing. “Highly accurate healthcare costing can be challenging. You often need to use a surrogate of actual costs,” he said.
The next presentation—delivered by Elliott R. Haut, MD, PhD, FACS, vice-chair of quality, safety, and service and professor of surgery at Johns Hopkins Medicine in Baltimore, Maryland—considered the benefits and challenges associated with trauma center activation fees.
“Trauma centers are like fire and police departments because we are required to be available 24 hours, 7 days a week,” Dr. Haut said. That level of expectation compels these centers to make “considerable investments in readiness,” regardless of patient volume or insurance status.
“Readiness costs are real, and someone has to pay for them,” he said, noting that trauma activation fees may be a viable solution. Trauma activation fees, which Dr. Nathens mentioned in his opening remarks, bills patients, via their insurance, for the readiness of the trauma center. This bill is in addition to other bills (emergency department-related changes, facility fees, and so on), and is a tiered charge based on trauma activation level.
“Trauma center activation fees are here to stay,” said Dr. Haut.
“The way you manage people is the most important part of implementing anything you do in trauma care.”
“I think standardizing the fee is a good idea as is in greater parity and transparency with these fees.”
Kimberly Davis, MD, MBA, FACS, chief of the Division of General Surgery, Trauma, and Surgical Critical Care at Yale School of Medicine in New Haven, Connecticut, offered practical suggestions for increasing revenue, including optimizing coding (considering conditions unrelated to the incident procedure in the perioperative period); standardizing order sets and care pathways to minimize complications; and understanding quality data and where there are opportunities (mortality index and the case mix index).
Closing out the session, Jason W. Smith, MD, PhD, MBA, FACS, chief medical officer at the University of Louisville Health in Kentucky, emphasized reducing variability in practice, specifically through external benchmarking and adherence to best practice guidelines, such as TQIP’s, as an approach to reduce costs and increase value in trauma care.
“There has been an exponential increase in traumatic brain injury (TBI) data since 2015,” said J. Claude Hemphill III, MD, MAS, professor of neurology at the University of California San Francisco, referring to the year the TBI best practices guidelines originally were published.
The soon-to-be-released updated guidelines feature input from every specialty that manages TBI care, from triage to follow-up and recovery, and includes new or expanded content sections on the following topics: blood-based biomarkers, tiered management of intracranial pressure, prognostic assessment and family communication, pharmacological management, and more.
One important update to the new best practices guidelines occurs in the imaging section. According to Dr. Hemphill, the guidelines now suggest that a negative head computed tomography scan no longer rules out TBI.
Strategies for implementing the best practices guidelines into a trauma center should include a gap analysis (determine current state and desired future state); an action/education plan (set expectations, establish leadership and other roles); and performance review (develop performance improvement metrics and a plan, integrate with TQIP outcomes).
“The way you manage people is the most important part of implementing anything you do in trauma care,” said Robbie Dumond, MHA, BSN, TCRN, AEMT, vice-president of operations at the University of Colorado Hospital in Aurora. “Change readiness should not be assumed.”
The 2023 TQIP Annual Conference on-demand content (general and breakout sessions) will be available for both in-person and on-demand registrants this month.
The 2024 TQIP Annual Conference will take place November 12–14, in Denver, Colorado.
Tony Peregrin is the Managing Editor of Special Projects in the ACS Division of Integrated Communications in Chicago, IL.