One of the goals of the Grey Book from the American College of Surgeons (ACS) is to make trauma center requirements absolutely clear. The good news is that many requirements in the 2022 Standards are very straightforward. However, ambiguities remain in several areas.
In particular, performance improvement (PI) standards continue to require nuance and perspective. In some cases, helpful information in the Orange Book has been streamlined out of the Grey Book. In this article, I take a closer look at five new trauma PI standards that can easily be misinterpreted.
Standard 7.2: Incorporating required audit filters into your written PIPS plan
Standard 7.2 requires all trauma centers to have a written PIPS plan. This plan must include (at a minimum) the 30 audit filters and reviews specified in the standard’s resources section.
This requirement is as clear as can be — just copy the list of audit filters and paste it into your PIPS plan, right?
Unfortunately, no. Implied, but not stated, is the fact that the trauma program must not just include the required filters in its PIPS plan but actually monitor them.
I recently spoke with a trauma program manager whose center hosted an ACS site visit in 2023. For the center’s ACS reviewers, the presence of the 30 items in the PIPS plan was just step one. They also wanted to see that all the required filters and reviews were being actively tracked and trended.
Here’s the lesson: To comply with Standard 7.2, you need to create a mechanism to ensure that all required audit filters, events and reports are reviewed regularly. I always recommend adding all 30 items (again, at a minimum) to your program’s PI dashboard. Program staff should track every item as part of their ongoing PI monitoring efforts.
Even if your center’s performance on a quality metric is perfect (e.g., zero unanticipated returns to the OR), you still need a mechanism for tracking it. And, of course, follow up on any adverse trends that you identify.
Standard 4.35: Understanding the nuances of PI staffing
With Standard 4.35, the ACS introduced specific staffing requirements for PI personnel. The nice thing about this standard is that it provides some concrete numbers to guide staffing decisions (and strengthen budget requests). The challenge is that many program leaders seem to be reading through the standard too quickly.
If you are confused by this requirement, just keep this in mind: It’s a threshold, not a ratio.
Standard 4.35 requires trauma centers to have:
- At least 0.5 FTE dedicated PI personnel when the annual registry volume exceeds 500 patients.
- At least 1 FTE dedicated PI personnel when the annual registry volume exceeds 1,000 patients.
Note that the standard does not say you need 0.5 PI personnel for every 500 patients in your registry. It simply specifies the PI staff that are required when your center surpasses two threshold points — 500 registry patients and 1,000 registry patients.
To clarify this point, I put together the following table:
| Annual trauma registry patient entries | Required dedicated PI personnel (FTEs) |
|---|---|
| 1,200 | 1.0 |
| 1,900 | 1.0 |
| 2,300 | 1.0 |
| 3,500 | 1.0 |
As illustrated above, any registry patient volume over 1,000 has the same requirement — 1.0 FTEs dedicated to trauma performance improvement.
Now, having clarified all this, an important principle remains: Your trauma program must have all the staff resources it needs to comply with the standards. Returning to the table above, while a center with 3,500 annual registry patients is required to have only one dedicated PI coordinator, it might very well need more. The overall point is that your center needs to have the staffing resources sufficient to comply with the full range of PI requirements.
Even here, however, trauma program leaders have options. Say your center has 2,300 annual registry patient entries. You must have at least 1.0 dedicated PI personnel. Given the workload, you could decide to hire additional dedicated PI staff. Alternatively, you could decide to share PI responsibilities across the trauma team. For example, while the PI coordinator would handle the bulk of performance improvement work, other PI tasks could be assigned to the TPM, the lead registrar and the injury prevention coordinator.
Standard 7.8: Managing NSA review without the 10% requirement
Reviewing nonsurgical admissions (NSAs) is key to ensuring that injured patients receive appropriate attention from the trauma program.
Under the Orange Book, the requirement was clear: Programs that admitted more than 10% of injured patients to a nonsurgical service were required to review all NSAs through the PIPS process (CD 5–18).
Since the 10% rule proved to be unrealistic for most U.S. trauma centers, it is no longer included in the Grey Book. But now the question is, “How do you narrow down the volume of NSA cases that need to be reviewed?”
Standard 7.8 provides guidance for closing NSAs in primary review: If there is no opportunity for improvement, an NSA can be closed at primary review if (a) the patient had a surgical or trauma consultation or (b) the patient’s ISS was less than or equal to 9.
However, this still creates a potentially significant caseload of NSAs requiring secondary review by the trauma medical director. Under Standard 7.8, the TMD must review any NSA case that (a) did not have a trauma or surgical consultation, (b) had an ISS greater than 9 or (c) had an identified opportunity for improvement.
The key to managing this caseload is to understand that a “review” does not need to be an exhaustive look at every aspect of patient care. It is permissible to use algorithm-based tools to separate appropriate NSAs from those require a deeper consideration.
Like many trauma leaders, I recommend that programs use the Nelson tool to assess NSAs that come across their desk.
According to an assessment performed by trauma leaders at UCHealth, the Nelson scoring algorithm “was designed to provide an objective measure with which to evaluate patients with a lower risk of injury-related complications and hence, are more appropriate for NSA.”
The Nelson tool scores patients based on seven criteria, each of which is worth one point:
| Nelson patient criteria | Points |
|---|---|
| Age > 65 years | 1 |
| 3 or more comorbidities | 1 |
| ISS < 10 | 1 |
| MOI = ground-level fall | 1 |
| No ICU admission | 1 |
| No need for surgical intervention | 1 |
| No blood products | 1 |
| < 4 points = inappropriate NSA 4 or 5 points = requires further review 6 or 7 points = appropriate NSA |
|
TMDs can use the Nelson tool to review NSAs quickly, sort out NSAs that were appropriate (6 or 7 points) and focus on cases that require an in-depth assessment. This approach allows the PI coordinator and the TMD to work through cases more efficiently during secondary review.
Standard 7.7: Performing PI on transfers to hospice
Standard 7.7 covers mortality review within the PI process. Importantly, the standard requires centers to review both trauma-related mortalities and transfers to hospice.
This is a source of confusion for many trauma leaders because they think of a discharge to hospice as equivalent to a discharge to a SNF or a long-term care facility. In fact, hospice discharge patients are very different, and these cases need to be reviewed as intensely as patients who die in the hospital.
According to Standard 7.7, “Transfers to hospice require review to ensure there were no opportunities for improvement in care that might have significantly changed the clinical course that ultimately led to the decision for hospice care.”
The standard requires both trauma-related mortalities and hospice discharges to be classified for potential OFIs, and they must be categorized as either “mortality with opportunity for improvement” or “mortality without opportunity for improvement”. Key issues include injuries that may have been survivable under optimal conditions, failure to follow standard protocols and suboptimal provider care.
It is worth noting that the Trauma Quality Improvement Program (TQIP) is fully aligned on this point. According to the ACS TQIP Benchmark Report FAQ for Spring 2023, “We categorize discharges to hospice as mortality because those discharges have substantial influence on the assessment of true mortality performance, and we do not want to inappropriately benchmark centers with disproportionate access to hospice.”
When reviewing hospice discharges, consider whether the patient was in hospice before coming to the trauma center. The “clinical course” for these patients has not really changed by anything that happened in the hospital. For reference, note this guidance from the TQIP FAQ: “[P]atients admitted from hospice and discharged back to hospice are coded as a discharged to home per the NTDS and will not impact mortality benchmarking.”
“Standard MIA”: Is a Systems/Operations Committee still required?
It was recently called to my attention that a familiar requirement from the Orange Book appears to be absent from the Grey Book — the Multidisciplinary Trauma Systems/Operations Committee.
Under the Orange Book, centers were required to have a process for addressing trauma program operational events (CD 16–12): “Typically, this function is accomplished by a multidisciplinary trauma systems/operations committee that examines trauma-related hospital operations and includes representatives from all phases of care provided to injured patients.”
In contrast, the 2022 Standards do not include a requirement for a specific committee to address operational events. Does this mean that trauma centers can disband their Multidisciplinary Trauma Systems/Operations Committee?
The answer is no. I base my thinking on three reasons.
First, Standard 7.9 (which covers trauma diversions review) states, “In all trauma centers, all instances of diversion must be reviewed by the trauma operations committee.” The measures of compliance for this standard consist of meeting minutes from the trauma operations committee review. So even though there is no direct requirement for maintaining an operations committee, it is presented as an essential part of compliance with this standard.
Second, meetings of the “operations/systems” committee are still referenced in the current ACS prereview questionnaire (PRQ). In section 7.3 of the PRQ, one instruction reads: “Upload minutes from PIPS committees during the reporting period, including operations/systems and multidisciplinary peer review meetings.” [emphasis added] So clearly, the ACS still regards the operations/systems committee as a key component of trauma center management, and ACS surveyors expect to able to evaluate the committee’s activities.
Third, no matter what the current standards specify, it remains the case that hospital operational issues can and do affect trauma care outcomes. For this reason alone, it still makes sense to maintain a Multidisciplinary Trauma Systems/Operations Committee for the sake of reviewing operational performance events and, when needed, devising corrective actions.