The first major revision of Resources for Optimal Care of the Injured Patient in nearly a decade will be released in spring 2022.
The 2022 Standards build on previous guidelines from the American College of Surgeons (ACS), and most of the changes are incremental developments. However, the new standards include several new expectations in staffing, quality, data management, resource availability, care protocols and operational processes.
Avery Nathens, MD, MPH, PhD, medical director of ACS trauma quality programs, outlined “the most impactful changes” in the new standards during the closing session of the 2021 TQIP Annual Conference. The following summary groups these new expectations by required action.
1. Meet new staffing and staff education requirements
The new ACS standards will require all trauma centers to have a dedicated performance improvement (PI) coordinator (Standard 4.34). This new requirement is tied to the number of patients in the trauma registry:
- If the annual patient volume exceeds 500, the center must have at least 0.5 FTE dedicated to PI.
- If the annual patient volume exceeds 1,000, the center must have a least 1.0 FTE dedicated to PI.
Dr. Nathens clarified during his TQIP presentation that the new staffing requirements are minimums. “Greater trauma center volumes might very well call for additional personnel,” he said. “The expectation is that you actually have enough personnel to comply with the standards in Category 7, which is the PI category.”
The new standards have also increased the required staffing level for trauma registrars (Standard 4.30). Trauma centers will now be expected to have 0.5 FTE dedicated registry professionals for every 200 to 300 annual patient entries in the registry. (Under the previous standards, centers were required to have 1.0 FTE registry professional for every 500 to 700 admitted patients.)
Changes to the volume standard
The new standards make a small change to the patient volume requirement for Level I trauma centers. The volume threshold is the same (1,200 patients), but the definition is changing from “admissions” to “patients who meet National Trauma Data Standard (NTDS) inclusion criteria.”
NOTE: For the new PI coordinator and registrar staffing requirements, the patient volume denominator includes all patients who meet NTDS inclusion criteria and all patients who meet the inclusion criteria of any hospital, local, state or regional registries the center participates in.
The 2022 Standards also include new education requirements that relate to the registry team. In all trauma centers:
- At least one registrar must be a current Certified Abbreviated Injury Scale Specialist (Standard 4.31).
- All staff members who have a registry role must take and pass the most recent version of the AIS course from the Association for the Advancement of Automotive Medicine (Standard 4.32).
- All staff members who have a registry role must take an ICD-10 course (or an ICD-10 refresher course) every 5 years (Standard 4.32).
These new requirements are in addition to the longstanding requirement that registrars participate in a course that covers abstraction, data validation and other registry-related topics.
There is also a new continuing education requirement for members of the registry team (Standard 4.33). All trauma registrars will be required to take 24 hours of trauma-related CE during a three-year verification cycle.
2. Create a more structured PIPS plan and demonstrate its effectiveness
The 2022 standards will require all trauma centers to have a written performance improvement and patient safety (PIPS) plan that covers defined processes and includes other specific content (Standard 7.2). Under this new standard, the PIPS plan must:
- Outline the organizational structure of the PIPS process
- Specify event identification processes
- List the audit filters and events that automatically result in a review
- Define the levels of review in terms of eligible cases, reviewers and close/advance decisions
- Specify the makeup and responsibilities of the multidisciplinary PIPS committee
- Outline an annual process for identifying the center’s PI priority areas
“Every year you should have focused areas for performance improvement that you put on paper and put your efforts into,” Dr. Nathens said. “Hopefully, within a trauma center everyone will be thinking, ‘This is what we’re going to focus on this year, this is what’s important to us’.”
In addition, the new standards require all centers to have documented evidence that their PIPS program is effective (Standard 7.3). Documentation must cover event identification, audit filters, loop closure, corrective actions and “strategies for sustained improvement measured over time.”
3. Create a data quality plan
The 2022 standards will require all trauma centers to have a written data quality plan (Standard 6.1). Centers must review their data quality at least once per quarter, and they must be able to demonstrate compliance with their data quality plan.
“The plan must require that there is a quarterly review of data quality,” Dr. Nathens said. “So you’re not reviewing data quality only when you’re doing a data submission, but there is an ongoing process to review data quality.”
4. Develop several new protocols and guidelines
The 2022 standards will require trauma centers to have protocols in place for a variety of patient cohorts and care processes.
Under the new standard for the care of injured older adults (Standard 5.6), Level I and II trauma centers must have protocols for identifying vulnerable geriatric patients and patients who will benefit from a geriatric specialist consult. These centers will also need to develop protocols for geriatric-specific issues like medication reconciliation, mobility screening, and management of dementia, depression and delirium.
All trauma centers will need a protocol for screening patients at high risk for mental health issues following injury and for referring them to a mental health provider (Standard 5.29). “Part of the goal with these standards is to focus on outcomes apart from just survival,” Dr. Nathens said. “This [standard]acknowledges the strong relationship between mental health issues and trauma, whether it is mental health issues that result in injury or mental health issues that follow injury.”
All centers will need to develop protocols for meeting the rehabilitation needs of trauma patients, including rehabilitation care needs during the acute phase of care (Standard 5.27) and planning and documenting rehabilitation care needed after discharge (Standard 5.28).
Adult Level II trauma centers and pediatric Level I and II centers that do not have a specialized orthopaedic trauma surgeon (as defined in the standard) will need to have transfer protocols that specify “the type of patients/injuries that will be transferred to a center with an OTA fellowship trained orthopaedic surgeon” (Standard 4.12).
In addition, all trauma centers will need to have treatment guidelines for four specific orthopaedic injuries (Standard 5.20).
5. Secure expertise in several new specialty areas
The 2022 Standards include new requirements covering the availability of surgical and medical experts.
Level I adult and pediatric trauma centers will need to have soft tissue coverage expertise “including microvascular expertise for free flaps” (Standard 4.22). “This could be a wide variety of people,” Dr. Nathens said. “An ENT can do this in some centers, plastics is the usual specialty that does it, but someone who can cover a wound with a free flap is what we’re looking for here.”
Level I centers must also have expertise available to treat craniofacial injuries (Standard 4.23). Specialties involved could be otolaryngology, oral maxillofacial surgery and/or plastic surgery, and this expertise could be provided by a single surgeon or a group of surgeons.
Level II centers will need to have expertise in cardiothoracic surgery continuously available (Standard 4.21). “The focus here is surgical expertise,” Dr. Nathens said. “You may have a general surgeon who is very comfortable in the chest who covers most of this. That’s fine. It’s ‘surgical expertise,’ it’s not necessarily ‘board certified in’.”
Level I and II adult and pediatric centers must have either continuously available replantation services or a triage/transfer process with a replant center (Standard 4.24). Level I and II centers must also have specialists in pain management (with regional nerve block expertise), physiatry and psychiatry (Standard 4.25).
All pediatric trauma centers (Level I and II) will need a child abuse (nonaccidental trauma) pediatrician on the medical staff (Standard 4.26). This individual can be a board certified or board eligible child abuse pediatrician or any physician with a special interest in child abuse/non-accidental trauma.
The new standards also include several changes to the required qualifications for specialty liaisons (Standard 4.5), including liaisons for geriatrics, orthopaedic trauma and anesthesia.
6. Meet new response time and resource availability standards
The 2022 standards make several changes to specialist response requirements and other requirements covering the availability of trauma center resources.
There are two main changes to neurosurgeon response requirements (Standard 5.17):
- First, the standards now reference neurosurgical evaluation. “We specify ‘neurosurgical evaluation’ rather than being at the bedside because much of the evaluation means looking at a CT scan and getting information about what the patient looks like,” Dr. Nathens said.
- Second, the requirements no longer reference “institution-specific criteria” for neurosurgeon response. Instead, the standard specifies four criteria (three specific clinical scenarios and “trauma surgeon discretion”) that mandate a 30-minute neurosurgeon response.
Similarly, the new standard for orthopaedic surgeon response (Standard 5.21) has moved away from “institution-specific criteria” and now specifies five criteria that mandate a 30-minute response to bedside.
There have also been significant changes to requirements governing IR response to hemorrhage control (Standard 4.15):
- Under the previous standards, interventional radiologists in Level I and II centers were required to respond within 30 minutes.
- Under the new standard, Level I and II centers must have the necessary personnel and physical resources so that endovascular or IR procedures to control hemorrhage can begin within 60 minutes of request.
The new standards also include requirements for the availability of medical imaging services based on service type and trauma center level (Standard 3.5). “These resources have to be available 24/7 within the time interval specified,” Dr. Nathens said. “This is the expectation for imaging availability, but it does not mean that everybody has to be imaged within these timelines.”
There is also a new requirement that final CT reports must be available within 12 hours of scan completion (Standard 5.26).
In addition, the new standards include three new requirements for OR availability, including the availability of a dedicated orthopaedic OR for non-emergent cases (Standard 3.3) and the existence of an OR scheduling policy that includes timely access targets based on urgency (Standard 5.22).
7. Academic trauma centers: Meet new (relaxed) education and research requirements
The 2022 standards will require Level I adult and pediatric trauma centers to have a “trauma rotation with defined objectives and curriculum” for senior residents (Standard 8.4).
The new standards also clarify that the 3-month trauma rotation does not need to be a contiguous three-month block; it can be made up of several shorter assignments throughout the year (Standard 8.5). Trauma surgery coverage can include PGY-3 surgical residents and fellows if needed (Standard 8.6).
In addition, the new standards modify the expectations around research and scholarly activities at Level I trauma centers (Standard 9.1).
Under the old standards, academic centers were required to publish 20 peer-reviewed articles per verification cycle. Alternatively, the center could have 10 published articles and demonstrate other scholarly activities.
Under the new standards, Level I centers must have all of the following:
- At least 10 trauma-related research articles
- Participation by at least one faculty member as a visiting professor, invited lecturer or speaker at a trauma conference
- Support of residents/fellows in defined scholarly activities
8. Level III centers: If neurotrauma provided, demonstrate appropriate resources
The 2022 standards create a new trauma center category: Level III Neurotrauma (LIII-N). The standards define Level III-N trauma centers as those that provide neurotrauma care for patients with moderate to severe TBI, defined as GCS of 12 or less at the time of emergency department arrival.
“This is already happening,” Dr. Nathens said. “There are already practices out there with neurosurgical care being provided in Level III centers for trauma patients, so now we’re setting some expectations around it.”
Under the new standards, LIII-N centers will be required to:
- Have cerebral monitoring equipment available (Standard 3.7)
- Have board certified or board eligible neurosurgeons available to care for trauma patients (Standard 4.10)
- Meet the same 30-minute neurosurgical evaluation requirement as Level I and II centers (Standard 5.17)
- Have a contingency plan for when neurosurgery capabilities are unavailable (Standard 5.19)
In addition, LIII-N centers must monitor the performance of their contingency plan within their PIPS program. LIII-N centers must also have a neurosurgical liaison (Standard 4.5).
9. Assess readiness to treat pediatric patients
The 2022 standards will require all trauma center Emergency Departments to evaluate their pediatric readiness (Standard 5.10). Under this new standard, centers must also have a plan to address any deficiencies.
According to information provided with the standard, pediatric readiness “refers to infrastructure, administration and coordination of care, personnel, pediatric-specific policies, equipment, and other resources that assure the center is prepared to provide care to an injured child.”
The standard references resources available from the National Pediatric Readiness Project, including a Pediatric Readiness Assessment and ED Checklist & Toolkit. ED leadership teams that complete the assessment will receive a pediatric readiness score and a gap report.
While this standard appears to be aimed mainly at adult trauma centers, it also applies to pediatric Level I and Level II trauma centers.
Standards book coming in Spring 2022
The ACS emphasizes that the standards described above are subject to change prior to the official release of Resources for Optimal Care of the Injured Patient: 2022 Standards. Trauma program leaders are encouraged to wait for the release of the official standards book before making any significant changes to program structures or processes.
The targeted release date for Resources for Optimal Care of the Injured Patient: 2022 Standards is Spring 2022. For a complete list of important dates, see Rollout timeline for new ACS trauma standards.