2022 TQIP Annual Conference Informs and Inspires Trauma Care Providers

“After 2 years of remote conferences, the energy in the general session room was palpable,” said Avery B. Nathens, MD, PhD, MPH, FACS, FRCSC, Medical Director of ACS Trauma Quality Programs, describing the 2022 Trauma Quality Improvement Program (TQIP^®) Annual Conference, which took place December 11−13 in Phoenix, AZ. 

“Like an extended family coming together for a reunion after several years apart, everyone was excited to come back together to learn, connect with each other, and take back valuable and actionable lessons back to their centers,” said Dr. Nathens. “Our theme, Leadership Promoting Wellness: Taking Care of Your Team to Take Better Care of Patients, showed through in our program, providing inspiration for all.”

The conference drew 1,711 in-person and 908 virtual registrants, and featured educational content aimed at helping trauma teams improve their responses to traumatic injuries and provide better outcomes for patients.

TQIP Update

Dr. Nathens opened the conference by providing an overview of TQIP initiatives and milestones from the past year, including the 100-year anniversary of the Committee on Trauma, which he called a continuous “quest for excellence” driven by the power of data, performance improvement, quality, and advocacy. 

Focusing on the wellness theme, Dr. Nathens noted significant staffing shortages in healthcare, resulting, in part, from pandemic-related stressors and burnout. “With burnout, we have disengaged staff, and this is a real problem,” he said, adding that burnout also leads to “blunted and distant emotions, a sense of helplessness, diminished motivation, and feelings of depression.” 

Citing a 2021 article published in JAMA Network Open, Dr. Nathens revealed that among nurses who reported leaving their current employment in 2018, 31.5% said it was because of burnout; a stressful work environment, inadequate staffing, and insufficient leadership were listed as the driving factors for those who reported leaving or considering leaving their positions due to burnout. 

As for physicians and burnout, Dr. Nathens cited a 2022 Journal of Patient Safety article that evaluated 13 studies of more than 20,000 physicians and residents. In this review, researchers found that there were three times more errors among physicians and residents who reported burnout. 

“The good news is it doesn’t take much to improve the wellness of staff if we have the support [at the systems level],” Dr. Nathens said, noting that “compassion is critical” because it can have a mediating effect on feelings of burnout and, potentially, patient safety. “We need to address burnout because it is the right thing to do for our staff and our patients.”

In terms of process improvement, Dr. Nathens said sustainable change is possible by “holding the gains and evolving as required” and by supporting “spread,” which occurs when learning in any part of the organization is actively shared and acted upon across the organization. “QI [quality improvement] is like raising a child—prior success does not guarantee future success, and past experience and expert advice are only a starting point,” he noted. 

He summarized TQIP resources that are intended to guide QI efforts, including the soon-to-be-released ACS QI framework and toolkit, as well as the ACS Quality Improvement Course: The Basics, released last year, which features content on data measurement and analysis, change management, and other related topics. 

Dr. Nathens concluded his presentation with an overview of TQIP program updates with a specific focus on the December 2022 version of Resources for Optimal Care for the Injured Patient, a new edition of the standards released in March 2022. The December version was based on user requests for clarifications, and instead of publishing a separate clarification document, a new edition of the manual was published at the end of year. Notable updates included clarifications related to standard 2.8, Trauma Medical Director Requirements; standard 2.11. Trauma Program Manager Reporting Structure; and 4.22, Ophthalmology Services. 

All site visits scheduled to occur on or prior to August 31, 2023, will be reviewed based on the 2014 standards, while visits scheduled to occur on or after September 1, 2023, will be reviewed based on the 2022 standards.

Managing Disruptive Behavior

In a well-attended session titled, “A Few Bad Apples or a Rotten Barrel?,” Barbara J. Martin, RN, MBA, and Brad Dennis, MD, FACS, both from Vanderbilt University Medical Center in Nashville, TN, provided strategies for managing unruly conduct, particularly when exhibited by leadership. 

“Organizational culture, which are the beliefs, values, and norms shared by the healthcare staff, determines behaviors that are rewarded, supported, expected, and accepted,” Martin said, noting that this culture exists “from the C-suite to the bedside.”

Disruptive behavior can surface at any time, but particularly in high-stakes settings such as the trauma bay. Challenges for providers working in this area include getting access to information, communicating information with the care team, and managing multiple tasks and processes. To curb disruptive behavior in the trauma bay and beyond, it is important to create an organizational culture that is based on teamwork and clarity of roles, according to Martin. 

“Create [an environment] that is psychologically safe with intentional debriefing, vulnerability from team leaders, [where] there are no secrets in the trauma bay, and where everyone is a safety officer. We all have the right and responsibility to speak up if we see something that is not right for the patient,” she said. 

“Unprofessional or disruptive behavior undermines a culture of safety. It’s not about you—it’s about the patient,” added Dr. Dennis, noting that there are three types of disruptive behavior: 

• Aggressive (yelling, threatening gestures, intimidation, public criticism)
• Passive aggressive (intentional miscommunication, sarcasm, condescending tone)
• Passive (absence, tardiness to meetings, lack of engagement, apathy)

In the healthcare setting, all three types of disruptive behavior can result in incomplete handovers or documentation and failure to adhere to safety and quality guidelines. 

Dr. Dennis also underscored the importance of providing constructive criticism in a reasonable manner to colleagues and staff. “Absolute harmony is unrealistic but engaging in feedback that is respectively delivered is the goal,” he said. 

As for unprofessional conduct as experienced by the patient, he outlined a behavior assessment tool, the Patient Advocacy Reporting System (PARS), that allows patients to make observations about their care. “What we know, based on the data, is that patient complaints are non-randomly distributed; surgeons with many complaints have poorer surgical outcomes, and clinicians with many complaints are at risk for lawsuits,” he said. According to Dr. Dennis, using data from PARS, interventions on 2,550 high-claims risk physicians at 175 sites across the US resulted in improved delivery of care for 82% of those assessed. 

Pediatric Trauma Survivor: Kaden’s Story

The 2022 Trauma Survivor Session featured the annual conference’s first pediatric patient story, which described the systems of care that led to a remarkable and inspiring outcome. 

Kaden Olsen was just 4 years old when he was run over by a tractor at his grandparents’ home in a rural California town 3 hours north of San Francisco. Riding along with his father and siblings, the tractor was moving down a bumpy hill when Kaden fell out and was run over by the left side of the tractor. As members of any trauma team are well aware, time is critical during these events. Considering the remote location of the farm, Kaden’s father Karl was compelled to drive down a country road with his son in order to meet the emergency medical services team. 

“I was blindsided by emptiness—a feeling I hope to never feel again,” said Karl Olsen. “It’s that feeling that the three kids we have now, become two.”

Kaden’s mother Kristy added, “I watched everything happen, and in my mind, I thought that I was losing my whole family all at once. As I was holding him, I could see that he was gurgling blood and blood was coming out of his ears.”

In fact, Kaden had suffered a broken femur, pelvis, and both arms. He also had crushed ribs and a significant amount of internal damage, including severely damaged lungs.  

The trauma team at Ukiah Valley Medical Center, now Adventist Health Ukiah Valley, rushed into action.

“We walked into the emergency room, and those double doors opened up and there were 30 people waiting for us, ready to help,” said Karl Olsen. “I said, ‘I’m the dad,’ and they went right to work…during the next couple of hours they were God’s hands to us.” 

Jenna Szymczak, RN, one of the members of Kaden’s trauma care team, described the moments after he arrived, “I was looking at this beautiful little boy…and I had to put my big girl boots on and fall back on the training that I had and the team that I trusted so much.” 

Dozens of providers treated Kaden and supported his family, from emergency medical services (EMS) in the field, to the Level IV trauma center at Adventist Health Ukiah Valley and Ziad Hanna, MD, FACS. 

“The first time I saw him in the ER [emergency room], I thought there was a 50% chance that he would not make it,” said Dr. Hanna via a video presentation during the session. “You can’t imagine how much pressure I had inside of me… What happens if he does not make it? How can you live with it? But at some point, you have to do what you believe is right, which [in Kaden’s case] was an emergency splenectomy.” 

Incredibly, Dr. Hanna was able to successfully remove Kaden’s spleen in 6 minutes before the young patient was transported via helicopter to the University of California-San Francisco Benioff Children’s Hospital Oakland (UCSF BCHO), a Level I pediatric trauma center equipped to handle Kaden’s severe condition. 

Aaron R. Jensen, MD, MEd, MS, FACS, a pediatric and trauma surgeon with UCSF BCHO, moderated the session. In describing the severity of Kaden’s case, Dr. Jensen underscored the importance of pediatric readiness, noting that a key component is “provider competence and confidence.” 

When asked by Dr. Jensen to comment on Kaden’s continuity of care, Karl Olsen said his son’s healthcare providers continued to make Kaden and his family feel like “someone still saw us, cared about us, brought us donuts, even after Kaden was moved to another floor.” 

Trust also was a key component of Kaden’s care. At one point, when the family asked about Kaden’s condition, Dr. Jensen informed them that Kaden was not stable. “He told us the truth. So, a few days later, when Dr. Jensen said Kaden was going to make it, I knew I could trust him,” said Karl Olsen.

Keynote Describes How Caring Makes a Difference

Stephen W. Trzeciak, MD, MPH—a physician scientist who studies the scientific effects of compassion on patient care—presented the Keynote Address.

“We are at a pivotal time in history. We’re in a pandemic combined with an epidemic of burnout…and this topic is more important now than ever before,” said Dr. Trzeciak, chief of medicine at Cooper University Health Care and professor and chair of medicine at Cooper Medical School of Rowan University in Camden, NJ. “Compassion is an emotional response to another’s pain or suffering involving an authentic desire to help,” he said, noting that compassion is a combination of empathy and action. “I am amazed by trauma folks’ technical skill and their compassion.”

Neuroscience researchers have used magnetic resonance imaging to link feelings of empathy with activity in the pain center of the brain, according to Dr. Trzeciak. They found that acting in a compassionate manner activates the reward center of the brain and is associated with positive emotion. “It feels good to help people,” he said. 

“Human connection can modulate how a person experiences pain,” added Dr. Trzeciak, coauthor of an article published in Intensive Care Medicine (2019) that revealed patient perception of greater healthcare provider compassion during a life-threatening medical emergency is independently associated with lower risk of developing symptoms of post-traumatic stress disorder (PTSD). 

Summarizing data culled from several studies outlined in his book, Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference, Dr. Trzeciak noted that communicating compassion to a patient takes anywhere from 40 to 60 seconds, although some physicians may think these interactions take longer than they actually do. 

Not only is compassionate behavior a key component in providing enhanced patient care, it also is an important element in maintaining healthcare team engagement. Similar to the 2018 study cited by Dr. Nathens regarding the nursing profession and burnout, Dr. Trzeciak mentioned a 2022 study published by McKinsey & Company that found having caring and trusting teammates was high among factors affecting nurses’ decisions to remain in their current roles. 

“You can have psychological safety [in the workplace] and accountability. It’s not an either/or,” he said, urging healthcare providers to strive for developing a “fearless team,” where everyone feels “comfortable sharing concerns and mistakes without fear of embarrassment or retribution,” and where team members are “confident they can speak up and won’t be humiliated, ignored, or blamed.”

Best Practices Guidelines: Mental Health Disorders and Substance Use

The ACS Trauma Quality Programs Best Practices Guidelines series provides recommendations for managing patient populations or injury types with special considerations for trauma care providers. The new manual—Best Practices Guideline for Screening and Treating Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient—was unveiled during a special session at the 2022 TQIP Annual Conference.

“Alcohol and substance use problems are prevalent and increasing among trauma patients,” said Karen J. Brasel, MD, MPH, FACS, professor and vice-chair of the Department of Surgery at Oregon Health & Science University in Portland. “More than 50% of hospitalized trauma patients have reported an alcohol and/or drug use diagnosis during their lifetime. At the time of admission, 20% have met the diagnostic criteria for an alcohol or drug use problem.” Substance misuse increases the likelihood of complications, mortality, an extended length of stay, and the need for critical care. 

Two primary objectives for trauma healthcare providers treating these patients are to improve outcomes and reduce recurrent traumatic injury. These aims may be achieved through substance use screening and intervention protocols such as the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach. According to Dr. Brasel, SBIRT helps trauma care providers determine which patients are at no/low risk, moderate risk, or severe risk for substance misuse. Depending on the results of the assessment, patients can be given a brief intervention, brief treatment (onsite or via referral), or referral for specialty treatment.

In a presentation that addressed post injury mental healthcare such as PTSD, Terri A. deRoon-Cassini, PhD, MS, professor of surgery, psychiatry, and behavioral medicine at the Institute for Health & Equity in the Medical College of Wisconsin in Milwaukee, acknowledged that patients “with unaddressed mental health issues and prior trauma are at increased risk for readmission and injury recidivism.” 

When screening for mental health disorders, Dr. deRoon-Cassini urged trauma care providers to select screening measures that have been “validated for the population with the traumatic injury” and to ensure that a positive screen “triggers a patient referral to a mental health professional.” Validated screening tools for PTSD and depression in adults include the Automated PTSD Screen, Injured Trauma Survivor Screen, Patient Health Questionnaire, and Peritraumatic Distress Inventory. 

She underscored the importance of educating healthcare providers on best practices for trauma-informed care, and she urged support for hospital-based violence intervention programs as approaches for improving patients’ mental health recovery after injury. 

“This guideline will bring all the pieces of the puzzle together so that you can decide how you want to do this in your facility,” said Jorie Klein, MSN, MHA, BSN, RN, director of the EMS-Trauma Systems Section at the Texas Department of State Health Services in Austin. She summarized practical steps for implementing the Best Practices Guidelines, which include:

• Create an interdisciplinary stakeholder workgroup
• Conduct a gap analysis to evaluate current practices
• Develop an action plan timeline
• Establish educational priorities
• Integrate the Best Practices Guidelines into the current Trauma Performance Improvement Patient Safety Plan
• Report metrics to trauma operations committee
• Identify opportunities for improvement

Implementing the Best Practices Guidelines at the hospital or systems level begins with wide dissemination of the guidelines, advised Klein, and should include buy-in from trauma leaders and others involved in quality and performance improvement initiatives. The PDF of the Best Practices Guideline for Screening and Treating Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient may be accessed at facs.org/media/nrcj31ku/mental-health-guidelines.pdf.

All TQIP General Sessions were recorded and will be available for on-demand viewing this month. Look for an announcement via email and on the ACS website.

The 2023 TQIP Annual Conference will take place December 1–3, in Louisville, KY. 

Tony Peregrin is Managing Editor, Special Projects in the ACS Division of Integrated Communications in Chicago, IL.