In June, a group of American trauma leaders issued a report that could reshape trauma care in the U.S. Under their proposal, civilian and military trauma providers would collaborate to improve trauma access for both civilians and soldiers while increasing national readiness for mass casualty events.
The group’s recommendations are detailed in A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury, a report issued by the National Academies of Sciences, Engineering, and Medicine (NASEM).
The report calls upon the president to set a national goal of achieving zero preventable deaths after injury and minimizing trauma-related disability. It also calls for integrated national trauma leadership, an integrated trauma data network, and coordinated trauma research and quality improvement processes.
Recently, Trauma System News interviewed Jorie Klein, director of trauma at Parkland Memorial Hospital in Dallas. Klein was a member of the committee that developed the NASEM report. As a leader in the U.S. civilian trauma system, she shared unique perspectives on how the proposed collaboration would affect trauma centers and trauma providers.
Q. One of the recommendations in A National Trauma Care System is to embed military trauma providers in civilian trauma centers. The idea is to give them a chance to keep their skills sharp between deployments. How will this work practically?
This process has been tested in Houston and other areas and is actually working quite well in several trauma centers across the country now — Cincinnati and San Antonio are two examples. The question is how to make it work on a larger scale.
Here is an example using our trauma center, which is a Level I trauma center. The first step would be to establish a contract with the Department of Defense (DoD) to send a team of trauma providers to Parkland. The potential team could consist of a trauma surgeon, an orthopedic surgeon, an anesthesiologist, an emergency physician, two OR nurses, two ICU nurses, two resuscitation nurses, a medic, a chaplain and an administrator. It’s important that the military team be an interdisciplinary, integrated team. If a nurse comes and works with us but she is not working with other military nurses and physicians, it defeats the purpose because the goal is to teach the military team to manage trauma patients and operate under trauma organizational structure leadership.
This team would actually be embedded into our trauma program. Our goal would be to schedule the military team to work on the same day so they would be managing issues together while they learn from the civilian trauma team. The result would be that they learn to work as a team with people they would actually be working with during a conflict. This would help build the infrastructure and trauma capabilities of the military because when they go into combat, they would have a competent, stand-ready team on Day One.
Q. What are the benefits to a civilian trauma center?
The advantage for the civilian trauma center is related to manpower and competency issues. If the trauma center has two ICU nursing vacancies, for example, those two military ICU nurses will fill those vacancies. If they are deployed, the military will replace them. There is usually adequate time to work out these replacement issues.
Another identified advantage is assistance in multiple casualty and mass casualty events such as what happened in Orlando. These embedded military trauma teams could not only help in their assigned trauma center, but they could also help in other hospitals in the community through integrated disaster response programs. These arrangements would benefit the military and civilian trauma system as well as the overall systems of integration.
Q. How would this affect trauma centers that may already be experiencing declining patient volumes? Are there enough serious blunt and penetrating injuries to go around?
The criteria and selection process to identify these trauma centers have not been established, but the process would likely consider the trauma center’s yearly volume of ISS > 15 patients, its percentage of penetrating trauma, its capabilities, capacity and surgical specialties, etc. The goal is to place these military teams in trauma centers that have the expertise and capabilities to help the military providers learn how to manage very complex trauma cases and how to manage resources.
This evaluation assessment could be aligned with the Needs Based Assessment of Trauma Systems tool that the American College of Surgeons developed. This would help ensure the military teams are in centers and regions with adequate volume to foster learning.
Q. The report calls for a national “learning system” for trauma care. Could you describe that?
A learning system is a continual process of evaluating what is happening and identifying areas that can be improved. It includes mechanisms to identify issues, address these issues through interventions, and then reevaluate outcomes. This aligns very nicely with a trauma center’s performance improvement and patient safety program.
I believe the trauma performance improvement process is the DNA of the trauma center. If a strong PI program is in place, it develops a strong trauma program. Strong trauma programs decrease mortality, decrease disability and decrease complications, which leads to a decrease in the cost of care. This means strong trauma centers are consistently evaluating their outcomes and identifying opportunities for improvement. These identified events have corrective actions implemented. These processes are reevaluated to define successes and additional needs. Weak trauma programs typically have weak PI programs. These centers don’t review in detail the care they are delivering. The constant learning system creates a continuous stream of improvements that positively impact patient outcomes.
Q. So the proposal would embed PI into trauma at a national level?
If you look at the NASEM report, one of the first recommendations is to establish national leadership and infrastructure to define, implement, monitor and maintain a national trauma system, which includes the military and civilian sectors working in an integrated collaborative practice. National leadership is needed to define the infrastructure, oversight and organizational processes to support these systems.
There are several leadership organizations with stakeholders who have a vested interest in alignment and collaboration in an interdisciplinary approach to trauma system development. The American College of Surgeons, the National Association of EMTs, the Society of Trauma Nurses, the American College of Emergency Physicians, the Emergency Nurses Association, the Orthopaedic Trauma Association and the Society for Neuroscience are examples of these organizations with their stakeholder members.
Q. The report recommends that civilian trauma adopt the military’s model of rapid innovation. The term used is “focused empiricism.” Could you explain that?
The concept of focused empiricism is to use timely data to identify issues and establish rapid interventions that improve patient outcomes or system performance. The improvements are then fast-tracked and the findings are monitored and rapidly disseminated to the stakeholder participants to ensure timely changes across the board.
An example of this process is the Stop the Bleed program. A national group of experts came together with data and identified that bystanders can stop the bleeding in the field. The goal of focused empiricism is better patient outcomes or more efficient, effective processes. The starting point is a data-driven analysis that provides facts. The empiricism process is then used to facilitate change. The standardized change is then pushed to all stakeholders for implementation. When you talk about focused empiricism, there is a standardized process for change. This process makes rapid improvements in the population of injured patients. It is important to note that it is a fast-paced, data-driven process.
Q. So this is what the military has done well?
The military does this very well, especially if you look at the opportunities they chose to work with. Some of their success stories are linked to preventative measures. For example, they found that war fighters had very specific injury patterns, so they modified their preventative gear. They reviewed the data, made some adjustments and made a significant difference in the outcomes and lives of the soldiers.
Q. The report puts a lot of emphasis on improving trauma data.
No healthcare organization wants to be recognized as being an “okay” trauma center. The goal is to commit to being the very best trauma center or trauma system. Data and data analysis serve to benchmark outcomes and provide the opportunity for data comparison. The data comparison defines high performers, those in the middle and those that need to change. Data quality and data that is accurate, complete and timely assist in building the infrastructure and linking all the pieces of the trauma system puzzle together.
So one of the committee’s recommendations is to capture more data on what happened to the patient before they arrived at the hospital. This includes questions such as, what did the police record identify? What did EMS do on scene? What happened when the patient arrived at the hospital? And what did the medical examiner report identify? The goal is to put all those pieces of data together so we can actually do a uniform analysis of what’s happening to these patients. What are our trends nationally, at the regional level and at the trauma center level?
Q. Many trauma centers are having trouble capturing data now. This sounds like a big expansion of performance metrics and data collection.
I don’t think the suggestion is that trauma centers need to collect more data. I think the data that’s being collected needs to be evaluated for quality. In other words, are we getting complete data sets and accurate data sets? The pieces of the puzzle that are missing in the current civilian system are police reports, rehab data and medical examiner data linked to an individual case. The committee recommends integrating these data elements into a more robust data set to evaluate trauma patient outcomes.
Q. The report calls for real-time access to patient-level trauma data. Could you explain what that would look like?
Texas has a fairly aggressive trauma system. But even in our state, individuals requesting good, solid, complete trauma data are looking at data from 2013 or 2014. The problem is that things can change rapidly.
The goal is to obtain current data to use in decision making. You would not want to establish your household budget based on three-year-old data on your income and expenses. But often trauma system priorities are based on data that can be five to ten years old.
One potential opportunity is to use hospital EMRs to help drive data availability and quality. Right now trauma centers are trying to integrate EMR systems with trauma registry systems. Trauma centers are also exploring options to obtain pre-hospital information and medical examiner information more timely.
It would be ideal for the trauma system leaders to have data that is current and accurate to set the national agenda and framework for development of an integrated system. This could be accomplished with a national directive to link police reports, pre-hospital data, trauma registry data, rehab data and medical examiner data — after all, this is the country that put a man on the moon.
Q. The report emphasizes the need to get trauma centers on a solid financial footing.
Unfunded care and underinsured care create a burden on the system. Reimbursement for trauma care needs to change. If a patient with a gunshot wound is driven to a trauma center by a private car versus an ambulance, it impacts billing. Did the care change for that patient? No, the standard of care was provided. Did the trauma center not use the same level of resources? The standard of care requires the same resources.
The same thing happens to EMS. Say there is a car crash with multiple injuries. Paramedics evaluate two patients and transport them, but a third patient is critical and the paramedics decide transport by medical air services is in the patient’s best interest. The paramedics stabilized the patient and initiated life-saving mechanisms, but under current billing regulations they can’t bill for a patient they did not transport. The committee recommends that billing be based on the level of care provided by the trauma center and pre-hospital providers.
Funding to implement, monitor and sustain the integrated trauma system infrastructure is critical. The infrastructure consists of local, regional, state and national oversight. Integrated systems link fire, police, EMS, air medical, trauma centers, rehabilitation facilities, medical examiners and education centers. This interdisciplinary stakeholder team builds processes for EMS triage, triage, transfers, trauma center designation, trauma registries, data management, outcome analysis, rehabilitation and disaster response for the developing system. Prevention, public education and professional development are additional critical elements of the trauma system. Benchmarking data and research are needed to evaluate and improve outcomes. Funding to support this infrastructure is almost absent.
The burden of injury in America is ignored by national leadership. In 2013, the Centers for Disease Control and Prevention defined trauma injury as the leading cause of death for individuals 1 to 44 years of age. Trauma causes more years of potential life lost, surpassing cancer, heart disease, chronic respiratory disease, liver disease and diabetes. Funding for trauma system infrastructure and research is lower than any of these disease processes. This has to change.
Q. Say I’m a trauma medical director or trauma program manager. I read this report and I’m energized by it. What should I do now?
To start, you really need to pay attention to what’s going on in America. I mean Orlando, Dallas, Baton Rouge, and other places are key examples of why the investment in trauma systems is needed nationally. These events can occur in any community, so all communities need to be prepared. And you can’t be prepared unless you have the infrastructure in place. This document from NASEM is asking for national leadership to establish, define and fund the infrastructure for trauma systems in America, both civilian and military.
So my first recommendation is you need to read this document. Second, you need to define what elements of the system are in place in your community or region and what is missing. This allows you to understand the gaps in your system. Once you complete this review you need to advocate for system development by contacting your local legislators and state leaders. The NASEM committee report’s aim is to have zero preventable trauma deaths after the injury has occurred. Stakeholders need to integrate and advocate for national leadership. My recommendation is that every trauma program manager and every trauma medical director, along with EMS and air medical directors, needs to engage at their state level. They must talk to their legislators and advocate for national trauma system development.
The first report that talked about the need for a national trauma system was Accidental Death and Disability: The Neglected Disease of Modern Society. That report is 50 years old. We haven’t done anything to fix this situation for 50 years! There have been Band-Aids, but the national attention to commit resources for national oversight of a trauma system is lacking.
America needs this infrastructure to save lives and stand ready. Whether you’re in Washington or Texas or New Jersey, there should be a standardized approach to the injured person in America.