The American College of Surgeons (ACS) Committee on Trauma will soon release Resources for Optimal Care of the Injured Patient: 2022 Standards — the first major revision of its trauma center resources document in nearly a decade.
Much of the new book will be familiar to trauma program leaders, but it also includes several new requirements. Trauma System News recently surveyed U.S. trauma professionals to find out which new requirements will create the biggest compliance challenges.
Overall, program leaders who responded to the survey expressed concerns about how the new standards will impact financial and professional resources.
- Their biggest concern is securing budget to comply with new staffing requirements for trauma registrars and performance improvement (PI) coordinators.
- Respondents also noted significant obstacles to securing the physician expertise required under several new standards.
- Many respondents worry that the new standards will be particularly burdensome for rural and Level III-IV trauma centers.
New trauma standards survey results
The survey was promoted in the January 2022 issue of Trauma System News, and it was available online January 7-31. A total of 184 individuals responded to the survey.
Survey respondents were first asked to indicate which new trauma center requirements would be the biggest challenge for their program. Here are the results:
| New volume-based FTE requirements for PI coordinators and registrars | 46% |
| New requirements for specialist availability (pain, physiatry, psychiatry) | 29% |
| New requirement to create a written data quality plan and review it quarterly | 27% |
| New expertise availability requirements (soft tissue, craniofacial, cardiothoracic) | 27% |
| New education requirements for trauma registrars | 26% |
| New availability requirements for replantation services (Level I and II) | 24% |
| New specialty response requirements (neurosurgery, orthopaedics, IR) | 24% |
| New requirements for OR availability (non-emergent ortho, timely access) | 23% |
| New requirement to document the effectiveness of the PIPS program | 22% |
| New requirements for specialty liaison qualifications (geriatrics, ortho, anesthesia) | 22% |
| New requirements to develop clinical protocols (geriatric, mental, rehab, ortho) | 21% |
| New requirement to perform peds readiness assessment, create deficiency plan | 17% |
| New requirements regarding the content and structure of the written PIPS plan | 13% |
| New availability requirements for medical imaging services (and final CT reports) | 11% |
| New medial staff requirement for a child abuse pediatrician (pediatric I and II) | 9% |
| New requirements for Level III centers that provide neurotrauma care | 8% |
| Modified expectations for research and scholarly activities (Level I) | 5% |
| Expectation that trauma rotation has defined objectives and curriculum (Level I) | 5% |
Staffing and education: Survey respondents expect that new staffing requirements for registrars and PI coordinators will be their biggest compliance challenges. They also expressed concerns about new education requirements for trauma registrars.
Specialty expertise and services: Respondents also anticipate problems recruiting specialists in pain medicine, physiatry and psychiatry; ensuring the availability of expertise in soft tissue coverage, craniofacial injuries and cardiothoracic surgery; ensuring the availability of replantation services; and meeting new response parameters for several specialties.
Planning and documentation: A significant percentage of respondents expect difficulties creating a written data quality plan and/or documenting the effectiveness of their performance improvement and patient safety (PIPS) plan.
Survey participants were also asked to explain their responses. More than 100 individuals provided detailed comments clarifying their concerns and describing the compliance obstacles they foresee.
A selection of comments from trauma program leaders are presented below. Some comments have been lightly edited for clarity.
Need to hire more registrars and PI coordinators
Close to half (46%) of survey respondents indicated that new volume-based requirements for trauma registrar and PI coordinator staffing would be a challenge for their trauma program. In their comments, several pointed to budgetary constraints.
“Our center is already outside the ratio for FTEs. Anything that pushes us to do more will be a significant stress.”
“Purse strings are tight and office space is nonexistent — increased staffing is a major challenge.”
“We are a high-volume adult Level III and just got a second registrar after 2 years of trying. It will be impossible to add an additional PI coordinator. It will require resources that are not available.”
Several respondents commented on the difficulty of working with hospital administration to address staffing needs.
“Obtaining new staff is always a challenge with leadership as they don’t understand trauma requirements.”
“Our volume drastically increased in 2021 — it will require a PI coordinator. Working with administration on that will be a hard sell.”
“Increased FTE requirements for programs are always met with resistance and attempts to circumvent them by administrative teams allocating human resources.”
Aside from budget constraints, labor shortages are also an obstacle to complying with new staffing requirements. Several program leaders pointed to the COVID-19 pandemic as a complicating factor.
“There is an employee shortage in healthcare and the [required staffing ratios are]not feasible during a pandemic when there are no available applicants. The mandate was created pre-pandemic and therefore does not take into account the people who quit or programs that do not have or will not have the required number of registrars/PI coordinators.”
“There already was a shortage of qualified registry staff — and it was made only worse by the pandemic. Where does the ACS expect these people will be coming from?”
A few respondents criticized volume-based staffing ratios per se. They argued that the standards should consider differences between trauma centers, trauma professionals and patient populations.
“Every registrar is different, and the volume parameters don’t take that into account.”
“Trauma centers vary in complexity of care. PI nurse and registry staffing based solely on NTDS inclusion and admission volume should have some flexibility if ISS scores and complications are low, as seen with single-system injuries. Trauma centers that see high-volume geriatric populations with low-energy fall mechanisms of injury should have some flexibility with their PI staffing — especially if care is standardized and [reflects]best practice and outcome quality data is above benchmark.”
Need to secure specialty services and expertise
The 2022 standards create several new expectations regarding the availability of physician specialists and physician expertise. About one-quarter of respondents indicated that one or more of these requirements will be challenging to meet for their centers.
Several respondents noted that many of the medical specialists required under the new standards are in short supply. The problem is worse in some regions of the country.
“Professional resources within our geographic location are limited and we are having challenges with recruiting and retaining providers for geriatrics, ortho, pain management, physiatry and psychiatry. In meeting these requirements, [we may need to employ]unconventional techniques such as telemedicine.”
“Some of these specialties are hard to find or tied to academic centers, making it harder for community Level I-II centers.”
“The new staffing for soft tissue coverage will be difficult in pediatric centers that may not have the surgeons available like adult centers. Could be tough to find and retain these surgeons.”
“CONSISTENT availability of medical staff specialists (craniofacial, soft tissue) is challenging and expensive.”
Many respondents commented on the requirement that Level I and II centers have either continuously available replantation services or a triage/transfer process with a replant center.
“This specialty is especially difficult as there are few resources, and those that have the qualifications/expertise do not want to be on call 24/7/365. I think we will need to tackle this on a county-wide level, where [replantation]is shared call by all the trauma centers in that county.”
“The process for developing a triage and transport plan with our replantation center is an unknown process. Guidance would be helpful.”
Need to meet new specialty response parameters
A few respondents noted potential difficulties complying with new response time requirements for neurosurgery and orthopaedic surgery.
“Currently our Level III center has a 60-minute response time because of where our neurosurgeon lives. Concern that we will not have NS after the new requirement.”
“We are NOT a teaching facility and function with only attending/staff orthopedic surgeons who are obviously not in-house 24/7. The fact that this new requirement states that an ortho surgeon must be at the beside for certain issues will be a very hard sell to our group of ortho surgeons. It would be helpful to have evidence stating an ortho surgeon at the bedside (vs. trauma surgeon or interventional radiologist) has been shown to change outcomes.”
Several respondents remarked on the operational challenges of tracking response times.
“Many consults are placed while the surgeons are in the trauma bays on cell phones with one another… Capturing the times is not as easy as one may think.”
“We have had difficulty getting our specialty providers to document their consult times and times to bedside for critical response times. There is no consistency, thus this will be a PI initiative this year.”
“Glad to see the IR response time better defined on the back end, but what about the front? The ‘decision’ time is extremely difficult to track down within the documentation and care of the patient.”
“There is a challenge in coming up with a system where ‘paged,’ ‘responded’ and ‘at bedside’ time is documented — without being cumbersome to providers and nursing staff. We have the providers, just not the mechanism for the documentation.”
Need to meet registrar education requirements
Approximately one-quarter (26%) of respondents indicated that new education requirements for trauma registrars could be difficult to meet.
“It will be a challenge to have a registrar certified as a CAISS. Many registrars have years of experience and have taken and passed the AIS courses but do not wish to take the CAISS certification exam. This is especially difficult with lower-volume centers.”
“While I agree that there should be set requirements for education and CEs for the registrars and trauma team that are involved in the registry, this will be a barrier (at first) to get everyone all the education needed to meet the requirements. I have a large registry team, so this can be seen as very time-consuming and some financial resources will have to be allocated to get them all the classes they will be required to have.”
One respondent noted that it is unclear how additional trauma registry education will be funded.
Need to have a dedicated ortho OR
The 2022 standards require Level I and II centers to have a dedicated orthopaedic OR for non-emergent cases. In Level III centers, OR access for orthopaedic trauma must be sufficient to ensure optimal fracture care.
Several respondents noted that high OR utilization rates and perioperative staffing shortages will make it difficult to secure a dedicated orthopaedic room.
Other respondents welcomed the new standard because it will help them obtain needed resources for the non-emergent orthopaedic population.
“I have been arguing for an orthopedic trauma room for 5 years and have made zero progress.”
“This new requirement is VERY appreciated and necessary. This will be a big ‘ask’ for my facility, but it is something important that has been discussed for several years. I think it will be difficult simply because it will likely require extensive adjustment and some financial commitment from my hospital.”
Need to document PIPS plan effectiveness
The 2022 standards will require all trauma centers to provide documented evidence that their PIPS program is effective. About one-fifth (22%) of respondents indicated potential difficulty complying with this requirement.
One respondent tied these challenges directly to staffing shortages and the pressure of COVID-19.
Special concerns of rural and lower-level trauma centers
Many survey respondents commented specifically on how the new standards will impact rural trauma centers and Level III, IV and V trauma programs.
“All of this is a huge increase for a small, limited hours for admin, Level IV trauma program.”
“We are a level V trauma center. The biggest issue is staffing for shifts as well as the added-on FTE registrar / PI processor. [Currently] one nurse does both and we do not have a full-time dedicated trauma registrar.”
“Rural trauma centers are financially disadvantaged to meet these standards. They may simply downsize or drop out.”
One responded commented on the challenges of running a strong PI program in a rural center.
Eager to move forward
The ACS expects to release Resources for Optimal Care of the Injured Patient: 2022 Standards in spring 2022. For a complete listing of important dates, see Rollout timeline for new ACS trauma standards.
While the survey focused on expected challenges and perceived problems, a few respondents commented on the value of the updated standards and expressed a positive view.