ACS releases December 2022 revision of trauma standards — what exactly changed?

The American College of Surgeons (ACS) has released the first update of Resources for Optimal Care of the Injured Patient: 2022 Standards.

The new December 2022 revision of the Resources Manual introduces several important changes. It expands the defined role of the trauma program manager, relaxes one aspect of the specialty coverage standard, provides a welcome clarification on trauma registrar education, and includes several helpful updates to required PIPS plan audit filters.

To download the latest version of the trauma standards manual from the ACS and access the official change log, visit Resources for Optimal Care of the Injured Patient (2022 Standards).

To find out exactly what changed in the revised edition, read the detailed summary below.

Greater emphasis on TPM responsibilities and shared leadership

The December 2022 revision of the Resources Manual significantly expands the required responsibilities of the trauma program manager (TPM) as described in Standard 2.11. In addition, several wording changes emphasize the key role that TPMs play in trauma program leadership.

First, it is worth noting that the title of Standard 2.11 has changed from “Trauma Program Manager Reporting Structure” to “Trauma Program Manager Responsibilities and Reporting Structure” (emphasis added).

In the original release, this standard required that TPMs have “a reporting structure that includes the TMD.” The December 2022 update retains this requirement but adds that TPMs must assume defined responsibilities “in conjunction with the TMD and/or hospital administration”.

The standard now lists several specific TPM responsibilities, including trauma program oversight, participation in the program budget process, development and implementation of clinical protocols and guidelines, monitoring of PI activities, trauma registry oversight, and representing the trauma program to hospital administration.

Changes to the Additional Information under Standard 2.11 mark a shift in tone. This section specifies that a “dotted line” reporting structure must exist between the TPM and the trauma medical director (TMD).

In the original release, the stated reason for this structure was to allow the TMD to provide “oversight and guidance” to the TPM and “ensure that the TMD has the opportunity to provide leadership to the TPM and partner with them in setting goals for the benefit of the program.”

The December 2022 revision has removed the oversight and guidance language. Now, the rationale for a dotted line reporting structure is to “ensure that the TMD and TPM are aligned in setting goals for the benefit of the trauma program and its patients.”

Finally, the Measures of Compliance section of this standard has been expanded. Previously, the sole compliance measure was “Relevant organizational chart”. Now, centers must also provide a “Role profile/description that highlights the responsibilities of the trauma program manager”.

Sporadic gaps in specialty coverage allowable under certain conditions

Standard 4.21 requires Level I and II trauma centers to have expertise in certain surgical specialties continuously available. Continuous is defined as available 24 hours a day, 7 days a week, 365 days a year.

According to the original edition, continuous availability “implies there are no gaps in coverage.” This requirement has been softened in the December 2022 update.

According to the revised Standard 4.21, “Sporadic gaps in coverage due to vacation/conference attendance, etc. must be addressed with a contingency plan.”

The update also provides clarification on the meaning of expertise in Standard 4.21: “Expertise implies that there is a surgeon credentialled by the hospital to provide acute trauma care for the services listed above.”

In addition, the December 2022 update has removed orthopaedic surgery, neurosurgery and ophthalmology from the list of specialties covered by Standard 4.21. Requirements for neurosurgery coverage are spelled out in Standard 4.10, while orthopaedic surgery requirements are covered in Standards 4.11 and 4.12. Requirements for ophthalmology expertise are now covered in the…

…brand-new standard for ophthalmology services

The December 2022 revision of the Resources Manual has added a new Standard 4.22. According to the standard, “Level I and II trauma centers must have continuous availability of ophthalmology.”

NOTE: Because this new standard has been inserted into the manual, all subsequent standards in the Personnel and Services category (Category 4) have been renumbered. For example, the standard on soft tissue coverage expertise, originally Standard 4.22, is now Standard 4.23.

Trauma staff not necessarily required to take latest AIS course

The original version of the 2022 Standards required every staff member with a trauma registry role to “Participate in and pass the most recent version of the AAAM’s Abbreviated Injury Scale (AIS) course”.

This requirement caused concern for many trauma professionals, because not all trauma centers have transitioned to the most current edition of AIS.

This standard has been modified in the December 2022 revision. Staff with a registry role are now required to take and pass the AIS course “for the version used at your center”.

(NOTE: The number of this standard has been changed from 4.32 to 4.33.)

Key changes to required PIPS plan audit filters, events and reports

The December 2022 update makes several changes to the list of audit filters, events and report reviews that must be included in a center’s written performance improvement and patient safety (PIPS) plan.

In the original edition, the audit filter list included “All nonsurgical admissions (excludes isolated hip fractures)”. This caused confusion for many trauma professionals because it seemed to contradict Standard 7.8, which requires programs to review all nonsurgical trauma admissions.

The December 2022 revision does away with this confusion by changing the item to “All nonsurgical admissions (refer to Standard 7.8)”.

Originally, the audit filter list included “Screening of eligible patients for psychological sequelae”. In the updated version, this item has been changed to “Screening of patients for psychological sequelae (LI/LII/PTCI/PTCII))”. This change aligns the item with Standard 5.29 (Mental Health Screening).

Similarly, the “Screening of eligible patients for alcohol misuse” item has been changed to “Screening and intervention for alcohol misuse”. This change aligns the item with Standard 5.30 (Alcohol Misuse Screening) and Standard 5.31 (Alcohol Misuse Intervention).

The “Neurotrauma diversion” item has been changed to “Trauma and neurotrauma diversion”. This change emphasizes the fact that the standards are concerned with all instances of diversion.

Finally, “Benchmarking reports” has been added to the list of items that must be included in the written PIPS plan.

Nonsurgical admissions standard is easier to understand

There has been no substantive change to Standard 7.8 (Nonsurgical Trauma Admissions Review). However, the wording of the requirements is much clearer.

The revised standard spells out which nonsurgical trauma admissions must be reviewed by the TMD in secondary review (no trauma/surgical consult or ISS > 9 or OFI identified in primary review) and which NSAs may be closed in primary review (cases with no OFI that either had a trauma/surgical consult or were ISS < 9).

Greater specificity regarding the new Pediatric Readiness Assessment

The original Standard 5.10 required the ED in every trauma center to “evaluate its pediatric readiness”.

In the December 2022 revision, this standard now specifies that the ED must perform “a pediatric readiness assessment”. In addition, the Resources section has been updated to point users directly to the National Pediatric Readiness Project Pediatric Readiness Assessment web page. Similarly, the Measures of Compliance section now specifies that the required gap analysis is the “Pediatric Readiness Assessment Gap Report”.

The update also clarifies that the assessment is not a one-time-only exercise. According to the revised standard, the Pediatric Readiness Assessment must be performed “during the verification cycle”.

Revised compliance measures for anesthesia availability

Standard 4.13 requires anesthesia services to be available within defined timeframes.

Originally, the Measure of Compliance for this standard included documentation of “time of request to time of response” for anesthesia clinicians.

Under the December 2022 update, this documentation is no longer required. According to the revised Measures of Compliance section, centers must provide the “Hospital or trauma policy on anesthesia services pertaining to availability and response time”. In addition, this section now notes that compliance will be “Evaluated during the site visit process”.

Postgrad education standards have been combined and amplified

Standards 8.4, 8.5 and 8.6 in the original edition have been combined into a single standard covering postgraduate education in Level I trauma centers. The new combined standard is numbered Standard 8.4.

The December 2022 update adds several new details to the requirements. For example, the Additional Information under Standard 8.4 now contains important details about the volume and breadth of trauma cases that residents should be exposed to. Along with this, the revised Measures of Compliance section includes “Number of major operative trauma cases over the course of the reporting period”.

New requirements for “affiliate” pediatric TMDs

Standard 2.8 outlines special requirements for centers in which the pediatric TMD is a general surgeon who is not board-certified or board-eligible in pediatric surgery.

The original release required these TMDs to have “a written affiliation agreement with a pediatric TMD at another verified Level I pediatric trauma center whose role is to assist with process improvement, guideline development, and complex case discussions”.

The December 2022 revision augments this language to clarify that the written agreement must be between the trauma center and the affiliate pediatric TMD and it must identify the affiliate pediatric TMD. The update also clarifies that the affiliate must be currently serving as pediatric TMD at an ACS-verified Level I pediatric trauma center.

In addition, the agreement must specify, at a minimum, that the affiliate pediatric TMD will “Assist with process improvement, guideline development, and complex case discussions … Attend at least 50% of trauma multidisciplinary PIPS committee meetings …[and]… Attend the VRC site visit at the time of verification”.

Several clarifications for centers undergoing initial verification

The updated standards include several clarifications that apply only to trauma centers undergoing a consultation or an initial verification review. These changes are designed to ensure that certain requirements are fulfilled during the 12-month reporting period preceding the review.

• Standard 2.10 requires TPMs to earn 36 hours of trauma-related CE during each verification cycle. The December 2022 revision adds that, for a center undergoing a consultation or initial review, at least 12 hours of this CE must be earned during the reporting period.
• Standard 2.12 requires that trauma centers implement at least two injury prevention activities (as defined) during each verification cycle. New in the December 2022 revision: If the center is undergoing a consultation or initial verification review, at least one of these activities must be implemented during the reporting period.
• Standard 4.34 (previously numbered 4.33) requires that each trauma registrar “accrue at least 24 hours of trauma-related CE during the verification cycle.” The December 2022 revision adds that, for centers undergoing consultation/initial review, at least 8 hours of this CE must be earned during the reporting period.

Helpfully, the December 2022 revision now includes explicit definitions of the terms reporting period and verification cycle. These definitions are now included in the Overview section under the “Verification, Review, and Consultation Process” heading:

• “The Reporting Period is defined as the twelve (12) month period ending with the calendar month preceding three (3) months prior to the site visit date.”
• “For verified trauma centers, the Verification Cycle is defined as the thirty-six (36) month period preceding the expiration date of the current verification status.”

Minor changes and clarifications

The December 2022 revision of Resources for Optimal Care of the Injured Patient: 2022 Standards also includes several minor adjustments and clarifications:

Hospital Regional Disaster Committee: In Standard 2.2, the “Hospital disaster plan” item has been removed from the Measures of Compliance.

Disaster Management Planning: In Standard 2.3, the Measures of Compliance section has been revised to clarify that in adult and pediatric Level I centers, an orthopedic surgeon (in addition to a trauma surgeon) must participate in disaster committee meetings.

Trauma Surgeon Requirements: In Standard 4.1, the requirement has been rephrased to clarify that trauma surgeons must have direct patient care responsibilities. (As worded in the original release, the requirements only applied to “Trauma surgeons who are involved in the care of trauma patients”.)

Disaster Management and Emergency Preparedness Course: Standard 4.36 (previously Standard 4.35) has been revised to clarify that completion of either the DMEP course or the eDMEP course satisfies the requirement.

Specialized orthopaedic trauma care: In Standard 4.12, details about alternate training criteria have been moved from the Measures of Compliance section to Additional Information. The wording has been expanded to note that alternate training criteria “are subject to approval after review of credentials and training.”

Specialty liaisons to the trauma service: In Standard 4.5, requirements for orthopaedic surgeon and anesthesia liaisons, and for alternate training criteria, have been clarified.

Orthopaedic surgeon response: Standard 5.21 has been revised to clarify that the attending orthopaedic surgeon (previously, just “the orthopaedic surgeon”) must be involved in clinical decision-making for defined orthopaedic trauma patients.

Multidisciplinary PIPS committee attendance: Standard 7.6 has been revised to clarify that the 50% meeting attendance threshold for radiology liaisons only applies Level I and II trauma centers.