TQIP annual meeting promotes strategies for improving trauma outcomes

The 2018 Trauma Quality Improvement Program (TQIP^®) Annual Scientific Meeting and Training, November 16−18 in Anaheim, CA, drew nearly 1,640 attendees, including trauma medical directors, program managers, coordinators, and registrars.

Highlights of the ninth annual TQIP conference included a keynote address by retired U.S. Army Colonel John B. Holcomb, MD, FACS, who served as a general surgeon in Somalia during the 1993 Black Hawk Down incident; updates and progress reports on TQIP and Committee on Trauma (COT) initiatives; presentations on preparing, training, and aftermath planning for intentional mass casualty events; lessons learned from a survivor of the Virginia Tech tragedy; the pediatric perspective on firearm-related violence; and a presentation on innovative patient discharge planning, including pain management and limiting opioids for trauma patients.

Enhancing trauma care for soldiers and civilians

“In between wars, civilians set the standard of care; during wartime, the military leads innovative trauma care. With military-style injuries increasing, it is imperative that we broadly implement lessons learned [on the battlefield],” said Dr. Holcomb, who spent more than two decades as an active-duty Army surgeon—a role in which he developed several key combat casualty care innovations.

In 1993, Dr. Holcomb was part of the surgical team that delivered two days of continuous care to soldiers injured in the Black Hawk Down incident. During this battle, Dr. Holcomb and colleagues worked feverishly to save the lives of Army Rangers, many of whom ultimately died as a result of exsanguination. This experience inspired the combat surgeon’s interest in improving hemorrhage control procedures. “It was clear that improved methods of hemorrhage control were required by manual compression—dressings and tourniquets,” he said. Dr. Holcomb helped reclaim the use of tourniquets on the battlefield—a treatment that was once thought detrimental to patient care because of its association with increased amputation rates resulting from restricted access to blood and oxygen.

By 2006, according to Dr. Holcomb, the benefits of tourniquets were reevaluated, and the military made tourniquet use standard practice. This life-saving bleeding control technique also has transitioned into civilian trauma care and has been used effectively to treat victims of the Boston Marathon bombing and other mass casualty events.

“The trauma center is too late,” Dr. Holcomb said. Major limb trauma without a prehospital tourniquet is linked to decreased survival rates, he noted, citing a recent study published in the May 2018 issue of the Journal of the American College of Surgeons that showed delayed tourniquet use was associated with 4.5-fold increased risk of mortality from hemorrhagic shock.

Another trauma care strategy has transitioned from the military to the civilian health care setting: the 1-1-1 blood transfusion protocol. Developed on the battlefields of Iraq and Afghanistan, the 1-1-1 comprises equal parts plasma, platelets, and red blood cells and has been shown to be the most effective treatment for a patient in danger of bleeding to death.

“We have made rapid progress in trauma care, and these are hard lessons that we cannot afford to lose,” Dr. Holcomb said. “We have identified issues on the battlefield and implemented multiple solutions. With the transition to the civilian world, we need to focus on the patient and on quality,” he said.

COT update

ACS COT Chair Eileen M. Bulger, MD, FACS, provided a high-level overview of recent COT activities, beginning with a description of the committee’s updated vision and mission statements. The revised COT mission statement, inspired by the National Academies of Science, Engineering, and Medicine (NASEM) report on avoiding preventable deaths from injury, is “to develop and implement programs that support injury prevention and ensure optimal patient outcomes across the continuum of care. The programs incorporate advocacy, education, trauma center and trauma system resources, best practice creation, outcome assessment, and continuous quality improvement.”

Dr. Bulger also outlined the COT’s strategic plan for the next five years, with a focus on the following areas:

• Member engagement
• Global engagement
• Education
• Trauma systems development
• Trauma center quality improvement
• Injury prevention and advocacy

Reporting on the status of the Stop the Bleed^® initiative, Dr. Bulger said the program has 37,000 registered instructors, has been taught to more than 450,000 students worldwide, and has attracted more than 4,500 Twitter followers. “The joke is—if you haven’t tweeted about your Stop the Bleed program, it didn’t happen,” she said, noting that a version 2 of the course is in development and is anticipated to be available in spring 2019.

Dr. Bulger also provided an update on the new COT Research Committee, which is charged with developing strategies to optimize the use of ACS COT databases for research. The committee will work closely with the Coalition for National Trauma Research, develop a research agenda for firearm injury prevention, and provide mentorship for clinical research scholars, among other goals.

The COT Injury Prevention and Control Committee priorities also were identified and include hospital-based violence intervention, intimate partner violence, older adult falls, distracted driving, and a firearm injury action plan.

Regarding the COT’s approach to firearm injury prevention, Dr. Bulger underscored the importance of finding common ground. “Our strategy has been to build a consensus-based approach and bring people together who may have very different views about firearms, about their benefits, about freedom related to use of firearms,” she said. “Along these lines, we’ve developed a number of resources for health care providers that you can use to help improve communication with patients and their families,” she added, referring to the Gun Safety and Your Health brochure and guide released in October 2018.

In addition, Dr. Bulger noted, “We recently received funding from the Department of Defense to carry out one of the key aims of the NASEM report, which is to develop the national trauma research action plan,” she said. “The grant, with an anticipated duration of three years, has three primary goals: develop a comprehensive research agenda that expands across the continuum of care, define long-term outcome metrics, and assess the regulatory environment.”

TQIP update

“Performance improvement is tough because change is tough—we are all averse to change. In spite of that, it is very clear that you are all the agents of change,” said Avery Nathens, MD, PhD, FACS, FRCSC, surgeon-in-chief, department of surgery, and medical director, trauma, Sunnybrook Health Sciences Centre, Toronto, ON, and Medical Director of the ACS Trauma Quality Programs. Dr. Nathens noted that more than 200 abstracts had been accepted for presentation at the conference, covering a range of issues, including changing your data collection, changing your registry, improving the quality of care for geriatric and pediatric trauma patients, improving bleeding control, and better organizing a trauma system. “You are all pushing against that resistance to change in order to do what is right for the patient,” he said, noting TQIP now comprises 809 trauma centers.

Dr. Nathens noted that the College has “embarked on a change project of its own. Our goal for the last couple of years was to bring together the ACS Quality Programs and allow them to build off of each other’s strengths and to do that we needed a common data infrastructure,” he said, noting that the ultimate goal of developing a common data platform was to create “new business intelligence tools and enhanced capability to improve the data quality that you see and to improve data validation, flow, and interoperability.”

In addition to describing new data platform enhancements—such as reports that allow users to view and export data used for TQIP benchmark reports and the ability to visualize model results and see data distributions and data elements used for risk-adjusted modeling—Dr. Nathens outlined how enhancements to data infrastructure allow data to flow from TQIP to the Surgeon Specific Registry. This means surgeons have the option to fulfill the CMS Merit-based Incentive Payment System (MIPS) Quality component by leveraging TQIP data and to earn a performance-based adjustment of up to 5 percent on their Medicare payments.

Dr. Nathens highlighted additional TQIP-related activities, including the following:

• The TQIP Collaboratives program
• Pediatric TQIP, which continues to support processes and outcomes relevant to the pediatric population with a specific focus on child abuse
• Additional enhancements to the TQIP Mortality Study to use the combined experiences of TQIP centers to identify patterns and design interventions to reduce preventable deaths—opportunities that are difficult to discern at the individual center level

Dr. Nathens also described the ongoing integration of TQIP and the Trauma Verification, Review, and Consultation (VRC) program. Based on a series of focus groups, plans are under way to modify the TQIP primer—provided to site reviewers before a center’s VRC visit to help the reviewer understand the center’s TQIP results—to a single page and to add specific questions in the prereview questionnaire (PRQ) on actions arising from benchmarking reports.

Mass casualty preparedness

Joseph A. Ibrahim, MD, FACS, medical director, Orlando Regional Medical Center, FL, outlined a three-point strategy for preparing for an active shooter event: recognize at-risk areas (open spaces, educational institutions, government buildings, private residences, and so on); obtain buy-in from stakeholders, including emergency medical services, law enforcement, city officials, and the community at large; and engage in “push to failure” in disaster preparedness training in order to determine a facility’s means for increasing capacity. “During these times, you don’t rise to the level of your expectations, you fall to the level of your training,” Dr. Ibrahim said. “We shouldn’t be saying ‘we didn’t think this would happen here’ anymore. Nobody has an excuse at this point not to engage in disaster preparedness drills.”

In addition, Dr. Ibrahim described the importance of preparing for the aftermath of mass casualty events, which includes activating a tiered response for the hospital workforce. “If everyone shows up at once, it will really be a struggle. You really need fresh legs and fresh eyes in the subsequent days of the event,” he said. It also is important to develop a clear communication channel with the operating room and to develop an understanding of “sufficient versus standard of care so that you can treat more patients and save more lives,” Dr. Ibrahim said.

“I would just echo many of the things that Dr. Ibrahim said—I think preparation and practice are really key,” said Deborah A. Kuhls, MD, FACS, FCCM, director of the University Medical Center of Southern Nevada, Las Vegas, trauma intensive care unit. “We need to do the most good for the most people, and that is a little different than our everyday jobs.”

Dr. Kuhls also described the importance of implementing a broad crisis support plan. “Beginning on day one, you need to start preparing for the emotional impact of these events. Prepare to be affected,” she said, noting that support should be available 24/7 to patients, families, physicians, and staff. A leader of the effort to provide trauma care in the aftermath of the October 1, 2017, mass shooting in Las Vegas, Dr. Kuhls noted that other lessons learned from that experience include implementing a communication plan, striving for organization of the patient flow, and using all available surgeons to operate or assist outside their subspecialty field.

To prepare for disasters other than active shooter situations, Eric M. Campion, MD, FACS, assistant professor of surgery, University of Colorado, Denver, suggested health care providers “prepare for the first, the worst, and the most.” Referring specifically to Asiana Airlines Flight 214, which crashed on final approach into San Francisco Airport in July 2013, Dr. Campion said that incident underscored the need for disaster preparedness beyond the initial emergency department triage to plan for high-use advanced imaging, operating room availability, and blood products, noting that in most mass casualty events, 20 to 25 percent of patients will require some blood. In the Asiana Airlines incident, injured individuals received more than 100 units of blood in the first 48 hours after the crash.

“It is critical to share your experience and let people know the lessons you learned after a mass casualty event—write about it and publish it,” said Dr. Campion, adding that while each individual health care provider may only experience one such event during their lifetime, it is important to communicate these lessons to ensure they are not forgotten.

Ronald M. Stewart, MD, FACS, Medical Director, ACS Trauma Programs, said trauma has three casualties: the injured patient, the health care provider, and other patients and the families of patients. “Exposure to the severe stresses of disaster, war, and trauma can produce unseen wounds for which we are all at risk,” Dr. Stewart said. “The elephant in the room is that while the emergency health care profession exudes confidence, leadership, and stoicism and the reflexive capacity to manage life and death circumstances, the culture of this profession potentiates the effects of post-traumatic stress and compartmentalizes it as an issue no one wants to discuss.” He described resiliency as a learned trait that “evolves through healthy responses to stressors.” As for management of stress specifically during a disaster event, Dr. Stewart suggested developing a buddy system with a coworker, implementing physical self-care (such as eating small quantities of food regularly), taking breaks when tolerance for irritation diminishes, and sustaining contact with family and friends for emotional support.

Kristina Anderson, a critically injured survivor of the 2007 Virginia Tech shooting, highlighted the importance of threat assessment to identify potential dangers and described practical ways to prepare for recovery after a mass casualty event. She cited research that “perpetrators do not snap. They plan in advance,” and typically display a “lack of resiliency or coping skills.” She outlined the pathway to violence beginning with violent ideation and grievance, followed by research and planning, pre-attack preparation, and the attack itself, noting that the potential for de-escalation via a threat assessment could occur particularly during the early phases.

According to Ms. Anderson, administrators and health care providers can prepare for recovery in the wake of a mass casualty event by developing an awareness of the full spectrum of survivors, acknowledging different approaches and timelines for healing, fostering openness and transparency, and planning for anniversary reminders of the event.

Firearm violence: A pediatric trauma perspective

“Gun violence takes a massive toll on American children. More than one in five U.S. adolescents ages 14 to 17 report having witnessed a shooting, and from birth to age 19, individuals in most rural U.S. counties are reportedly as likely to die from a gunshot as those living in the most urban counties,” said Colleen Kraft, MD, FAAP, president of the American Academy of Pediatrics (AAP). “How do we look at these statistics and not think of this violence against children as a noncommunicable disease?”

According to Dr. Kraft, the AAP in early 2018 launched a Gun Safety and Injury Prevention Research Initiative. The project will involve “experts from around the country to study and implement evidence-based interventions,” specifically with a public health epidemic approach in mind.

Dr. Kraft also highlighted legislative progress at the state level since the Sandy Hook shootings in 2012, including more than 270 state laws intended to reduce gun violence. Colorado, Delaware, Nevada, Vermont, and Washington have enacted new universal background check requirements, she said, and California, Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York, and Oregon have strengthened existing background check laws. She encouraged health care leaders to continue their advocacy efforts, in part, by developing effective communication strategies around the public health issue of pediatric firearm violence, to test the messages in focus group environments, and to refine these messages using an iterative process.

Brendan T. Campbell, MD, MPH, FACS, the Donald W. Hight Endowed Chair in Pediatric Surgery, Connecticut Children’s Medical Center, Hartford, spoke on family-based education initiatives, specifically the ACS COT Injury Prevention Committee’s Tablet-Based Firearm Safety Project. This app-enabled screening tool features a series of 10 questions related to firearm ownership along with a brief, three-minute firearm safety message. Developed in 2017, the tool—intended for parents of pediatric patients—was pilot tested in 10 centers. The results, according to Dr. Campbell, suggest that “parents of pediatric patients are receptive to receiving anticipatory guidance on firearm safety, with two-thirds of the parents stating the safety message would change how firearms were stored in their homes.”

Amanda Wong, Deputy City Attorney, Los Angeles, CA, Gang and Gun Prosecution Section, noted that gun violence is responsible for approximately 35,000 deaths annually in the U.S., with most gun-related deaths categorized as suicides (65 percent) followed by homicides (35 percent). Risk factors for potential firearm-related violence include substance abuse, domestic violence, bullying, anger management issues, depression, and impaired cognition, Ms. Wong said. She described gun violence restraining orders, which prohibit an individual from owning, using, or possessing a firearm, as “powerful tools for disarming a person and preventing them from acquiring additional firearms.”

The benefits of a hospital-based mentorship program to curb violence-related recidivism in young adults was the focus of a presentation by Martin S. Keller, MD, FACS, FAAP, trauma medical director, St. Louis Children’s Hospital, MO. The Victims of Violence Program, launched in 2014, offers 24-hour phone access to social workers who counsel parents and children ages 8–19 and provide mediation support and parental skills modeling. A total of 160 families have participated in the program, with 69 families successfully completing the program—none of whom have returned to the hospital with interpersonal violence-related issues. The recidivism rate for those who declined to participate in the program was 10 percent.

Discharge planning

Four speakers addressed the challenges of implementing an effective discharge plan. Jennifer Gantman, MSW, ASW, a trauma social worker with Cedars-Sinai Medical Center, Los Angeles, described the primary discharge barriers among trauma patients, specifically the “operational bottlenecks between acute care and postacute care.” Ms. Gantman suggested “establishing quality standards of patient-centered care to mitigate the potential for readmission and foster self-efficacy after injury” and called for the use of the “organizational and clinical strengths of trauma social workers to facilitate quality care transitions.” She said that social work in health care has a long history of providing “responsive patient care” that is associated with fewer readmissions and shorter lengths of stay.

Jessica L. Gross, MD, FACS, assistant professor of surgery, Wake Forest School of Medicine, Winston-Salem, NC, described how her institution has decreased postdischarge opioid use among trauma patients while maintaining patient satisfaction through a standardized approach, which includes the following:

• Setting expectations on admission and distributing and displaying an opioid handout
• Providing a transition plan from plain oxycodone to formulations with acetaminophen
• Encouraging multimodality pain therapy
• Discharging patients with an opioid-weaning plan
• Educating patients about risks and benefits of opioid use

Joseph T. Giacino, PhD, director, rehabilitation neuropsychology, and research associate, department of physical medicine and rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, defined Post-Intensive Care Syndrome as “new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization.” He described several new trauma rehabilitation initiatives, including a collaboration between the ACS COT and the American Congress of Rehabilitation Medicine that resulted in a position statement on best practices for trauma rehabilitation. Dr. Giacino also called for common data elements for all trauma populations in order to track acute and longitudinal trauma data and foster investigation of recovery trajectories.

Joseph V. Sakran, MD, MPA, MPH, FACS, director, emergency general surgery; associate chief, division of acute care surgery; and assistant professor of surgery, The Johns Hopkins Hospital, Baltimore, MD, also emphasized the importance of linking existing rehabilitation data to trauma registry data. In fact, the limitations in trauma registry data mean little is known about the prevalence of chronic pain after trauma, according to Dr. Sakran. He underscored the importance of understanding the association between post-traumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury and pointed to research that suggests that early acute care interventions targeting these disorders improves functional recovery after injury.

The 10th annual TQIP Scientific Meeting and Training will take place November 16–18 at the Hilton Anatole, Dallas, TX.