Interview with Eileen Bulger, MD, new chair of the ACS Committee on Trauma

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Trauma surgeon Eileen Metzger Bulger, MD, FACS was recently appointed chair of the American College of Surgeons Committee on Trauma (COT).

Dr. Bulger is the chief of trauma at Harborview Medical Center in Seattle, where she directs both the adult and pediatric trauma programs. As the 20th chair of the COT, she brings a diverse background in patient care, injury research and trauma system leadership.

Trauma System News recently talked to Dr. Bulger about the future directions of the COT and what she hopes to accomplish during her term.

Q. What are your top goals as the new chair of the COT?

Bulger: This is an exciting time for the Committee on Trauma, because there is a lot of active work being done in several areas. My goal in part is to try to see some of our current initiatives through to completion. Our top priorities right now are in implementing the recommendations of the 2016 NASEM report. That report focuses on the goal of zero preventable deaths and disability from injury, which is a goal I think we can all rally behind. We have divided that into four areas of focus:

First, we are interested in optimizing trauma system governance and working on having a platform across the country to ensure there aren’t any gaps in access to trauma care and ensure we have a strong framework for disaster response across the country.

Second, we are interested in integrating data collection across the continuum of care. We have a great hospital data collection system through the TQIP program, but we really lack the linkage with prehospital data and with long-term functional outcomes and rehabilitation data. We’re looking at ways to expand that data continuum so that we have good quality data to guide system improvement.

Third, we’re working hard on different models of military-civilian integration. This concerns the challenge of maintaining the readiness of our military healthcare providers in times of less conflict. I think there is a win-win situation if we can develop creative partnerships with the military and training platforms for them in our Level I centers. The COT has been very active in collaborating with the Department of Defense (DOD) on what that might look like and how to benefit both sides of the equation.

Fourth, in the area of trauma research, we’re working on advocacy efforts to obtain sustainable funding and a coordinated approach to research priorities. It’s been recognized for many years that trauma research is grossly underfunded relative to the burden of disease, and this is an area where I think we have some opportunity to really bring the whole trauma community together. The COT has been working with the Coalition for National Trauma Research (CNTR) to develop a national trauma research action plan and secure the funding to support it.

Q. Are there any other priorities you want to focus on?

Bulger: Another priority is our response to the growing number of mass shootings in this country. There are really two areas that we’re focused on. One is hospital and system preparedness to handle these events. That includes community training in the basics of bleeding control through the Stop the Bleed program. The COT has taken on as our mission the goal of training every citizen in the United States in bleeding control. That’s a big task, but much like CPR we think this is a critical piece of knowledge for every citizen. We are also working through advocacy efforts to make bleeding control supplies available in schools and public places.

In addition to that, Dr. Stewart has done an incredible job of trying to open a dialogue around firearm injury prevention. He has brought together diverse groups of people who have very strong views about the role of firearms in our society and asked them to think about the areas we can work together and build consensus. I’d like to continue that work, because if we can prevent these mass shootings, that would be ideal.

The other avenue that I want to focus on is our international growth. Our goal is to improve trauma care around the world. One side of that is education. The ATLS program has been the main focus of that, but we have also done a lot of work in developing countries using the TEAM program and other ACS educational opportunities. The other side is working with other countries as they develop their trauma systems, and we’ve done a lot of work in Latin America in that regard. There’s a lot of interest and enthusiasm in the international community in partnering with the COT, so we are excited about that as well.

Q. In connection with Zero Preventable Deaths, you mentioned optimizing trauma system governance. What would that look like?

Bulger: In terms of the regional development of trauma systems in various states, we have had great “pockets of success.” Of course all politics are local — and that’s the way trauma system governance should be — but I think there is an opportunity to establish some federal standards for minimum trauma system elements. We are certainly not looking at some sort of federal takeover of the trauma systems that we’ve built, but I think filling in the gaps in our country will be beneficial to regions that don’t have good access to care.

We need to keep thinking about how we structure and distribute trauma centers to meet population need, which is something the COT has been working hard on from a scientific perspective. Our goal is to make sure that every citizen in the country has access to the highest quality trauma care.

Q. That brings us to the NBATS tool. Will you be advocating for the inclusion of “regional need” in the verification process?

Bulger: The NBATS tool is still in evolution, and right now “version two” is being studied. Ultimately we do need to pay attention to the relationship between volume and outcome, which is true in many surgical disciplines and I think is true in trauma care as well, specifically high-acuity trauma care. But what that is going to look like, I don’t think we know yet. We’re still studying the problem and each iteration of the tool gets better.

Q. Is “outcomes-based verification” on the near horizon?

Bulger: I wouldn’t call it the near horizon. It’s a long-term goal that we have. The TQIP program gets stronger every year as new centers come on and we get more experience with data collection and data quality. We have been working for several years now to integrate the TQIP program and the verification program. Right now there is not an absolute outcome requirement for verification, but outcomes are evaluated and TQIP reports are reviewed at the time of verification.

I think if we get to the point where we are confident in the quality of the data, it could be an option to say a center that has really good outcomes maybe doesn’t need to be reviewed every three years. Maybe they go to every five years or something like that. I don’t think we would eliminate structure and process in favor solely of outcomes, because you need all three. But it would be nice to think about ways to integrate outcomes data better as we become more confident in data quality.

Q. Let’s return to trauma research. Could you explain the plan in more detail?

Bulger: I think the first step is getting everybody working together. Through the CNTR we have put in a grant to the DOD — which is under review right now — to help us create a national trauma research action plan, which is one of the things called for in the NASEM report. To do that we’ve engaged all the specialty societies that care for trauma patients. We’ve reached out to the orthopedists, the neurosurgeons, the pediatric surgeons, and the burn surgeons to work together on building this research platform. We’re also focusing on the entire continuum of care, so this includes researchers engaged in prehospital care, injury prevention, and rehabilitation. The grant proposal we put together would bring all those groups to the table to think about a comprehensive research agenda. Once you get people at the table and you have a structured way of creating your priorities, then you have a really powerful group for advocacy.

We are bringing all these organizations together to advocate for sustainable funding and a coordinated federal home for trauma research — which in my view should be the National Institutes of Health, but we’ll have to see how that plays out. It’s a really important priority. It’s important to the COT and all the other professional trauma organizations that we move this ball forward.

Q. You have a personal background in prehospital medicine. What’s the best way to bring hospital-based and prehospital trauma providers together?

Bulger: Prehospital care has been a huge interest of mine. For the last 10 years I have had the opportunity to work with the Resuscitation Outcomes Consortium, which really studied the problem of prehospital care for injured patients as well as for cardiac arrest patients. I think there is a lot of opportunity there, because prehospital providers are the first opportunity we have to intervene in the care of the patient. It is important that we are part of their protocol development and their triage decision-making about what hospital they should take patients to. It’s really incumbent upon us to be at the table and to be part of those discussions.

Finding a way to consistently link data across that continuum is going to help us with that. We need a global identifier that goes on the patient at the time of injury and follows them all the way through the system. I’ve said it before, but it’s kind of silly that I can track my Amazon package from every distribution site across the country online, but I can’t track a patient from the prehospital system through the first hospital to the second hospital much less to rehab. The first step is thinking about creative ways to track patients, not only in times of disaster but for everyday care, and build a unified data set that we can use to study the system and identify problems.

Q. You have led several “exception from informed consent” studies. What are the challenges?

Bulger: We absolutely have to study interventions in the prehospital setting, because we have to understand what works and what doesn’t work. When new therapies or care strategies are proposed, we have to have a platform to study that.

That platform does involve the exception from informed consent, and those regulations are very detailed. It’s an important and high regulatory bar to meet, but it can be done. A lot of the studies we’ve done over the last 10 years with the Resuscitation Outcomes Consortium have defined the best practices for how to engage the community in the process of community consultation and notification, how to design studies that are easy for paramedics to implement, and how to design studies that will really answer the important definitive questions.

Q. Shifting gears, how big is the problem of provider burnout in trauma? What is the solution?

Bulger: I think burnout is a problem for all physicians, nurses and other caregivers, particularly those who take care of patients in these stressful emergency settings. We do need to focus on taking care of each other, supporting each other, developing a sense of community for each other. I don’t know that I can solve burnout, but I think we have to be very sensitive to it and very conscious of the stress on us, particularly with some of these major events, and think about ways to support each other better through those types of events. It’s really important to cultivate a sense of camaraderie and community and look out for each other, and I think the trauma community has always done that very well.

Q. Of all the trends and developments that are happening right now in trauma, which do you think will ultimately have the biggest effect on improving the system?

Bulger: I think our greatest advances have come from eliminating variability in quality of care and adopting best practices across all our centers, particularly evidence-based best practices when they’re available. The TQIP committee has done a great job at developing best practice guidelines that provide resources to our centers. They are coming out with one now on imaging best practices, which I think will be really phenomenal, particularly for the pediatric trauma community as providers try to decide what’s the optimal imaging for a child to minimize radiation exposure but not miss an injury. Bringing people together to figure out what works the best and then get that widely adopted is a key strategy to improve care, not only in trauma but all of medicine. Getting people to work together collaboratively on solutions to system problems is probably the key to optimizing access to care and quality of care.

Certainly there are going to be technological advances and new intervention strategies that will advance care. I think access to blood products in the prehospital setting will really be a key advance. They’re doing that now in air medical services. It’s almost impossible logistically to do that in ground-level EMS services, but if we can really develop a freeze-dried plasma product that can be universally used in ground units, I think that would be an advantage for patients in shock that need resuscitation. That’s still in the research phase, but it’s on the horizon.

Q. What is your superpower?

Bulger: I don’t know that I have a superpower (laughs) — I can’t fly, I can’t see through walls.

If you want to know what my strength is, I think it’s in bringing people together and trying to be inclusive and build consensus.

Q. What can the trauma community expect from you?

Bulger: I hope they can expect from me all of my passion and energy committed toward the goals that I discussed. What I expect from them is that they continue to work diligently on these issues, be enthusiastic and be motivated — because there’s a lot we can accomplish if we’re all moving in the same direction.

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