DHS 118 Advisory Committee

7/25/16

Participants: Steven Rush, Patty Hinderman, Annette Bertelson, Cinda Werner, Ryan Neville, Lacey Huset, Dr. Marshall Beckman, Gary Neville, Jenny Ullsvik, Julie Forcier, Caitlin Washburn

Miscellaneous Items

Add some of the notes to the comments section so that we don’t miss anything that we have talked about before
Potential scope issue
WHA believes that we may have strayed a little from the guiding principles of not exceeding what is in the orange book and the minimum floor requirement
For example, some requirements were listed for IIIs and IVs in this document, but were only listed for IIIs in the 2014 standards
WHA will send these concerns to Julie who will distribute them to the group
The group will discuss this during the final review of the document

Reviewing the pink standards

Chapter 5: Hospital Organization & The Trauma Program

Criterion:CD5-5 (Level IIIs): The TMD must be a current board-certified general surgeon (or a general surgeon eligible for certification by the American Board of Surgery according to current requirements) or a general surgeon who is an American College of Surgeons Fellow with a special interest in trauma care and must participate in trauma call.
Discussion:
In the past, have allowed level IIIs to have EM doctors be their TMD as long as there was a general surgeon working alongside them
Opinion of most members of the committee is that this change should be made
In some hospitals, the surgeons are not involved at all and this is a problem
When the TMD is an EM doctor, their care stops in the ED and in a Level III facility there is a lot more care then just the ED
The review of care past the ED has been a struggle and has been a missed criteria for a lot of hospitals during site reviews
One hospital (at least) has an orthopedic surgeon as their TMD
This may be something to think about since the new requirement only says general surgeon
What is the current requirement?
State has allowed an EM physician to be the TMD
But in many hospitals this is not working
Would be helpful to have a TMD training course for Level III and IV centers
Surgeons are not involved in Level III trauma centers and this is a problem
The difference between a Level III and Level IV center is surgeon directed care
The point of this new standard is that we want the TMD more engaged with care, review of cases, etc.
The gold book says that is should be a surgeon
Most of the committee believes that a surgeon is better for the inpatient care, but surgeons may not have the time to fulfill this role
Another concern is that there may be a fair amount of Level IIIs that would not be able to meet this standard
Is there any way to pull how many Level IIIs have an EM doctor as a trauma medical director?
Not really and Kelly only got 3 responses from RTACS for the survey about ATLS
Also would be interested to see how involved the surgeons are in this process already
If you give people (surgeons in this situation) a chance to opt out, they will
Steven will reach out to their members to see how many hospitals this would impact (how many hospitals have non-general surgeons as their TMD) and see what their surgeon commitment/involvement is in terms of meetings, case reviews, developing policies/procedures, etc.
Will ask the trauma coordinators
This is an administrative support issue – if this requirement is supported by hospital administrative, hospitals have been able to bring in a general surgeon to be the TMD
Concern over whether the surgeon will actively participate
For most surgeons, when you bring them in to a meeting to talk about cases they won’t be quiet
This is the national standard and this is something that is instrumental
Look at all of the places that have failed their site visits and look at who their TMD is Also look at the current undesignated hospitals in the state and who their TMD is
PI is one of the major reasons why hospitals fail site reviews
Site reviews are not public
Decision: Will collect data about this criterion and will discuss this at a later meeting.

Criterion:CD5-5 (Level IVs): The TMD must be a current board-certified emergency medicine physician (or emergency medicine eligible for certification by the American Board of Emergency Medicine according to current requirements) or a general surgeon who is board certified in a surgical specialty or an American College of Surgeons Fellow with a special interest in trauma care and must participate in trauma call.
Discussion:
Where is this coming from?
Chapter 23 of the orange book does not list this as a standard for Level IVs
This is the current standard in Appendix A
In appendix A there is no board certification requirement for TMD
Believe this comes up as a requirement for emergency medicine physician in Chapter 7
Orange book does provide many standards for Level IVs so that is part of why a WI version of this standard has been created
The ACS does not talk about Level IVs in this part of Chapter 5
The ACS greatly enhanced the standards for Level IIIs but only touched on Level IVs in a few places
There will be some standards that are not in the orange book that do apply to Level IVs in Wisconsin
Why does the ACS have fewer restrictions for Level IVs?
Not really sure, question for the ACS
This standard was developed from the original checklist that the ACS provided
Level I and IIs had to fill this out before their site visit – this was an addendum to the gold book
Appendix A came from this checklist butwas adjusted to fit the WI system
There were things that wererecommended by STAC and approved by DHS over the years, but all of these changes have not been documented in a single place yet
Decision:Come back to figure out whether this is a current standard or a change. Come back to discuss after the emergency medicine chapter is reviewed.

Criterion: CD5-9: The TMD must have the authority to manage all aspects of trauma care.
Discussion:
How is this different from the current standards?
Managing all aspects of care – meaning including involvement past the ED
This is completely new – but this may be duplicative and be in another CD
Currently when reviewing Level IIIs, site reviewers have seen this as part of the job description created by hospitals for their TMD
While this standard is new, this seems like something that hospitals are already doing
Could put in the footnote that this came from current job descriptions for TMDs and reference the place in Appendix A where the need to provide job descriptions is listed
Current footnote is that a TMD has a surgical background
Decision: When the decision on CD5-5 is made, determine if this is duplicative and if we can take this out.

Criterion:CD5-11: The TMD, in collaboration with the Trauma Coordinator, must have the authority to correct deficiencies in trauma care and exclude from trauma call the trauma team members who do not meet specified criteria.
Discussion:
Level IVs are not listed in the 2014 standards so this is an example of customizing the standards to fit the needs of Wisconsin
When this was brought to the committee before, adding IVs to this criterion didn’t seem to be an issue
The only piece that is new in the orange book is “in collaboration with the TMD”
Are there deficiencies in hospitals in this area that make this necessary for Level IVs?
Surgeons really can’t do their job without doing this
Belief is that most hospitals already do this in conjunction with their quality departments
It is common for trauma coordinators to coordinate at multiple hospitals that are close together and that the quality department is at the “hub” and may be disconnected to what is actually occurring
This criterion is meant to ensure that the quality and trauma departments are working together
The trauma coordinators are the experts so it’s really important that the trauma coordinator is involved in this process
In general, it is helpful to have some comments about what documentation a hospital can provide to satisfy a criterion
List examples such as meeting minutes, agendas, etc.
Decision: Make a list of where we have added Level IVs and discuss later. The group is generally okay with this even for Level IVs.

Criterion: CD5-11: In addition, the TMD must perform an annual assessment of the trauma panel providers in the form on Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) when indicated by findings of the PIPS process.
Discussion:
This is completely new and was changed because the Joint Commission went to OPPE
Is it necessary for the TMD to do this specifically?
Yes, want the TMD to be aware if there are any performance issues or other outstanding issues
Does not mean that the TMD is doing the actual review
Just means that the trauma director reviews it, is aware of it, etc.
Clarify this in the footnote
Is there a better way to word the “when indicated” section
Put the when indicated before the FPPE
Potentially put a definition of OPPE and FPPE in the footnote
How can hospitals meet this criterion for locum providers?
Can use a simple measure to monitor them
They can call in for meetings or the hospital can send the minutes for the locums to sign off on
The company providing the locums should be doing OPPEs also
There are different ways that a hospital can do this– just need to show that they are involved in reviewing and providing feedback
Should already be in someone’s contract to perform these duties
The medical staff coordinator collects a lot of this
Decision: Change standard to say …and when indicated by findings of the PIPS process, Focused Professional Practice Evaluation (FPPE). Add in the definition of OPPE and FPPE. Add in examples of how hospitals can meet this criterion for theirlocum providers.

Criterion: CD5-12: The TMD cannot direct more than one trauma center.
Discussion:
This is a brand new requirement
What is the clinical reason for this? Does this occur now?
This does happen and it is not the best idea
But it may be okay for a TMD to direct more than one trauma center as long as they are practicing at both places
It may be difficult to perform this job to the necessary level at two different facilities
Is there a concern that this would compromise patient care?
If someone wants to do this they can, but the reviewers will look at this very carefully
What if someone wants to be a TMD for a Level III and IV?
This standard only talks about Level IIIs
What about being the TMD at more than two facilities?
Seems like it would really be a challenge for someone to be a TMD at more than two places
Does it need to be verified that no one is the TMD at more than two facilities currently? WHA has offered to look in to this
Decision: Change this to: The TMD cannot direct more than two trauma centers.

Criterion:CD5-13: The criteria for a graded activation must be clearly defined by the trauma center, with the highest level of activation including the six required criteria:
Confirmed blood pressure less than 90 mm Hg at any time in adults and age-specific hypotension in children,
Gunshot wounds to the neck, chest, or abdomen or extremities proximal to the elbow/knee
Glasgow Coma Scale score less than 9 with mechanism attributed to trauma
Transfer patients from other hospitals receiving blood to maintain vital signs;
Intubated patients transferred from the scene – OR –
Patients who have respiratory compromise or are need of an emergency airway. Includes intubated patients who are transferred from another facility with ongoing respiratory compromise (does not include patients intubated at another facility who are not stable from a respiratory standpoint)
Emergency physician’s discretion.
Discussion:
These are the minimal activation criteria
New parts of this standard:
“Extremities proximal to the elbow/knee” - new national standard
Change in the coma scale from less than or equal to 8 to less than 9
So there is no real change, just a change in wording
Decision: Okay. However, need to make the list look like it does in the orange book on pg. 38.

Criterion: CD5-16: The emergency physician may initially evaluate the limited-tier trauma patient, but the center must have a clearly defined response expectation for the trauma surgical evaluation of those patients requiring admission.
Discussion:
This is an all new standard
Hospitals need to further define this for admitted patients
This applies to hospitals that have a second tier response
Need to define what the surgeons required response is
What is a reasonable response expectation?
To be determined by the facility
There is not a national definition/standard right now
Kelly called the ACS to ask about this and took from this conversation that less than 12 hours was close to what they are looking for and they did not want to encourage 24 hours as a reasonable response expectation
Do not see this come up often in Level II criteria patients
Does “clearly defined response expectation” need to be defined?
There are differences all across the board for different hospitals
Maybe provide a range of acceptable response times
Surgical service means all surgeries, not just general surgery.
Decision: Okay. Take out the footnote.

Criterion:CD5-17: In Level III centers, injured patients may be admitted to individual surgeons, but the structure of the program must allow the trauma director to have oversight authority for the care of these patients.
Discussion:
This is somewhat redundant
Add a footnote: individual surgeon can include specialties such as ortho, neuro, plastics, ophthalmology, obgyn, etc.
Does this requirement help with the concern about the TMD not being involved if they aren’t a surgeon?
Decision: Okay. Add a footnote that clarifies that the individual surgeon can include specialties such as ortho, neuro, plastics, ophthalmology, obgyn, etc.

Criterion:CD5-18: Programs that admit more than 10% of injured patients to non-surgical services must review all non-surgical admissions through the trauma PIPS process.
Discussion:
How many programs hit that 10% mark?
Most or maybe even all
All a hospital needs to meet this criterion is a guideline that says a patient can be admitted to this surgeon at this time and then the hospital just needs to review all of the cases
This is a new requirement – right out of the orange book
Decision: Okay.

Chapter 6: Clinical Functions: General Surgery

Criterion: CD6-1: General surgeons caring for trauma patients must meet certain requirements, as described herein. These requirements may be considered to be in four categories: current board certification, clinical involvement, performance improvement, and patient safety and education.
Discussion:
What is new here?
The performance improvement piece of this standard
Right now, at Level IIIs, all surgeons are not required to participate in the PIPS process
At Level Is and IIs, all of the surgeons are required to participate
Will this requirement be to attend 50% of the meetings?
Participation does not necessarily have to mean attending meetings
Will not get all of the surgeons at a Level III center to attend 50% of the meetings
It does say that each member of the surgical grouphas to attend 50% of the meetings(CD6-8)
Decision: Determine if this needs to be modified based on discussions about some of the other criteria.

Criterion:CD6-2: Board certification or eligible for certification by the American Board of Surgery according to current requirements or the alternate pathway is essential for general surgeons who take trauma call in Level III trauma centers. CD6-3: Alternate criteria for non-Board certified surgeons in a Level III Trauma Center. Alternate pathway: (a) evidence that the non-US or non-Canadian trained surgeon has successfully completed a residency training program in general surgery, with the time period consistent with years of training in the US. This completion must be a certified letter from the program director. (b) Documentation of current status as a provider or instructor in ATLS program. (c) List of 48 hours of trauma CME in last three years. (d) Documentation that the surgeon is present for educational and at least 50% of all PIPS meetings. (e) Documentation of membership or attendance at local and regional or national meetings during the past three years. (f) A list of patients in the last three years with ISS and outcome data. (g) PIPS assessment by the TMD demonstrating that the morbidity and mortality results for patients treated by the surgeon compare favorably with comparable patients treated by other members of the trauma call panel. (h) Licensed to practice medicine and approved for full and unrestricted privileges by the hospital credentialing committee. (i) All will be evaluated by the reviewing team during the site visit process and determined to be adequate with oversight by the CRC.
Discussion:
Who does the alternate pathway criterion apply to?
Right now it says for just non-US and non-Canadian trained physicians
Do we want to change who the alternate pathway applies to?
Maybe make it apply to special circumstances, etc.
This is written into a lot of bylaws at facilities
Do we know if there are surgeons that are not boarded?
Locums possibly
Are they board eligible?
Are board eligible for the first three years of practice
Would a locum be able to meet the requirements under CD6-3?
Whether they can and whether they do are two different things
If we say that this is an equal bar for non-US and non-Canadian physicians, how is this not an equal pathway for US physicians as well?
Training in Russia and China is very different from the training in the United States
3 years instead of 5 or 6
Pre-med criteria is not the same
Credentialing is much less
Not getting the same training as they are in the US or Canada
Also not eligible to sit for a board in the US
Would this be achievable (criteria in CD6-3) for the special circumstance of retiring physicians that don’t want to sit for boards again?
The other question is, are they a fellow of the ACS?
Many times if they have been around for a long time, they have been grandfathered in to the system
The American College of Surgeons is a professional organization that is completely separate from the board of surgery
Fellow of the ACS is different than a fellow in a medical program
What is the result on board certification in patient care?
Board certification does not eliminate mistakes or bad outcomes
It is clearly documented in research however that more patient hours/education in surgery provides better outcomes
Locums are a big problem in this system – no way to give feedback to them
There is a care issue with them
The alternative for hospitals would be to divert instead of using locums, is this better?
Just looking for a hospital process to provide feedback to locums
This standard was changed in the green book
If you want a non-board certified locum to be on the trauma team, the hospital wouldhave to show that they meet the alternate pathway requirements
This is a joint commission standard also
Should CD6-1 and CD6-2 apply to a surgeon in aLevel IV facility that does surgery (neuro, ortho, etc.)?
In the eyes of the ACS, Level IVs do not have the resources available to do any surgery
But in Wisconsin we have a lot of hospitals that have a hybrid system with some capabilities to treat patients that need a higher level of care
The idea behind this standard is that we want to utilize our resources in the system in the best way possible
Making this a requirement for IVs?
Not requiring them to do more, but requiring them to meet these standards if they do perform surgeries.
Decision: Take out the non-US and non-Canadian language.Make this a requirement for Level IVs as well?

Criterion: CD6-7: For Level I, II, and III trauma centers, the attending surgeon is expected to be present in the operating room for all operations.