The American College of Surgeons (ACS) Committee on Trauma will soon release the first major revision of Resources for Optimal Care of the Injured Patient in nearly seven years. But while the new standards are the biggest news for trauma centers, the ACS is set to roll out several other changes in coming months.
These upcoming changes impact all verified trauma centers, and they affect several ACS trauma quality initiatives — including the Verification, Review, and Consultation (VRC) Program and the Trauma Quality Improvement Program (TQIP).
Trauma System News recently spoke with Avery Nathens, MD, MPH, PhD, medical director of ACS trauma quality programs, and Melanie Neal, senior manager. They previewed several new developments in verification standards and other quality initiatives that trauma leaders will see in the next 12 to 18 months. They also explained how these changes will further the College’s goal of integrating all its trauma quality initiatives.
1. The new standards will include more mandatory performance metrics
Many requirements in previous editions of Resources for Optimal Care of the Injured Patient included vague terms such as “appropriate” and “timely.” According to Dr. Nathens, the new standards will not only be more concrete, they will clearly specify how compliance should be measured.
“The new standards will be much more prescriptive about what metrics need to be captured and reviewed,” he said. “We think this is going to make things much easier for the centers and help them with their PI [performance improvement]process.”
2. The ACS will simplify the PRQ by pulling some documentation directly from TQIP data
Completing the Pre-Review Questionnaire (PRQ) is a complex and time-consuming task. In the near future, the ACS will simplify the process by using a center’s TQIP data to serve as documentation for some standards.
“The fact is that a lot of the data you need to fill out the PRQ is already in our TQIP database,” Dr. Nathens said. “For example, we already capture data on certain patient volume metrics. For these data points, there is no need for centers to have to figure out which patients meet the criteria.”
According to Melanie Neal, the process will be introduced when site visits on the new standards begin.
“In terms of timing, we first need to develop a new PRQ that is based on the new verification standards,” she said. “In addition, we will be migrating to a new platform for managing PRQs as well as scheduling site visits and other administrative aspects of verification. That will probably be rolled out at some point in 2022.”
3. The new standards will incorporate some Best Practices Guideline recommendations
One of the College’s goals is to better coordinate all of its trauma quality programs. “We have made an effort to align what we say in the Best Practices Guidelines with what we say in the verification standards and what we present in the TQIP reports,” Neal said.
As part of this effort, some recommendations that were first introduced in Best Practices Guidelines will be incorporated into the new trauma center standards.
For example, Best Practices in the Management of Orthopaedic Trauma recommends that soft tissue coverage be completed in a timely manner for open fractures that require skin grafting or soft tissue transfers. The new verification standards will include specialist staffing requirements designed to support this recommendation.
“A bad lower extremity fracture might require a plastic surgeon to help cover the bone,” Dr. Nathens explained. “So now there is a standard coming out that actually requires the right surgeon to be available to ensure that soft tissue coverage can be offered to patients with these fractures.”
4. Some Best Practices Guideline recommendations will be incorporated into TQIP reports
Similarly, some recommendations in Best Practices Guidelines will soon be reflected in TQIP benchmark reports.
For instance, Best Practices in the Management of Orthopaedic Trauma includes recommendations on timely antibiotic therapy for open fractures. TQIP began collecting data on related practices in January 2020, and TQIP benchmark reports will start including these results as early as fall 2021.
“This data is going to be in TQIP reports moving forward so centers can see how consistent they are in providing antibiotics in a manner consistent with the guidelines,” Dr. Nathens said.
Another example is timeliness of operative intervention for patients with spinal cord injury. The new Best Practices in the Management of Spine Injuries, which will be released this year, includes recommendations on timely intervention for this patient population, and future TQIP reports will include data on related practices.
5. ACS reviewers will start referencing Best Practices Guidelines during chart reviews
ACS quality leaders also plan to incorporate Best Practices Guidelines into the site visit process. According to Dr. Nathens, reviewers will soon begin referencing appropriate guidelines during the Medical Record Review session of the site visit.
“If the reviewers see opportunities for improvement when they are reviewing charts, they will likely make reference to those best practices,” he said. “The idea is to create awareness around these guidelines to ensure that patients have the opportunity to receive the optimal care from centers participating in our programs.”
The new site visit agenda includes scheduled time for a review of the trauma center’s TQIP benchmarking report (see ACS announces major changes to trauma center verification).
The expectation is that trauma program leaders are familiar with their TQIP reports and are using them to identify opportunities for improvement. The ACS does not expect centers to have resolved all potential OFIs at the time of a survey.
“For example, there are centers — and mine is one of them — where there are a number of opportunities for improvement within the TQIP report. However, you can’t focus on all of them at once,” Dr. Nathens said. “So if reviewers visited my site, I would say that we decided to put effort into A, B and C this year and will work on D, E and F next year.”
According to Dr. Nathens, a high outlier result in a TQIP benchmarking report will not in itself result in a deficiency.
“We have already made the decision that if performance is poor on a TQIP report, we are not going to fail a center as a result of that,” he said. “The expectation, though, is that the TQIP report is used to help inform decisions about where they are going to put their efforts in terms of performance improvement, and that’s probably sufficient from my perspective. We would like to hear that they have looked at the report and they’re working on a plan.”
6. All Best Practices Guidelines will be enhanced with PI tools
Recent Best Practices Guidelines include various tools for using the performance improvement process to implement guideline recommendations. For example, the new Best Practices Guidelines for Acute Pain Management in Trauma Patients includes a gap analysis assessment tool, recommendations for creating an implementation workgroup and suggested PI outcome measures.
According to Dr. Nathens, the ACS plans to build PI tools into future best practice reports —including the upcoming monograph on the mental health sequelae of traumatic injury, such as PTSD, depression and anxiety.
“The new guideline will include a gap analysis tool to help program leaders identify areas they need to work on and a PI tool that allows them to evaluate how good their implementation is,” he said. “Our goal is to make PI and implementation very easy for centers. They will not have to figure out how they’re going to evaluate how they’re doing. That material is already part of the best practices.”
Dr. Nathens also said that PI tools will be added retroactively to previously published guidelines.
“We are just starting the revision on our first best practices guideline effort, Geriatric Trauma Management Guidelines, and that document will soon have tools to allow for a gap analysis and an internal PI assessment,” he said.
7. Trauma standards will be aligned with the requirements of other quality programs
In addition to its trauma quality initiatives, the ACS also has quality programs for disciplines such as bariatric surgery, cancer and breast disease. In recent years the College has focused on reducing inconsistencies that exist between these various quality programs.
“When we developed our new trauma center standards, we looked at the other ACS standards — for example, standards pertaining to geriatrics or complex GI surgery — and tried to make sure we incorporated the right components of those standards into our trauma standards,” Dr. Nathens said.
For example, other quality programs within the ACS will include timeliness of hemorrhage control for gastrointestinal bleeding. The new trauma center standards will be aligned with these other requirements so that hospitals have one set of benchmarks to achieve.
The new trauma center standards will also adopt the same nine-category format used by other ACS standard programs. In addition, all ACS quality programs will be migrating to a common platform for data and administration.
According to Neal, these moves will benefit both trauma program leaders and hospital administrators.
“Consistency across programs has created efficiencies for us, which hopefully will turn into better customer service for trauma centers,” she said. “It will also lead to some administrative simplification for the hospitals that participate in our programs. If you’re an administrator at the hospital, this will make it easier for you to look across the various ACS quality programs and understand how they work.”