Trauma Verification Q&A Web Conference August 23, 2016 COTVRC@facs.org
Your Trauma Quality Programs Staff Tammy Morgan Manager Trauma Center Programs Molly Lozada Verification Manager Trauma Verification Rachel Tanchez Site Visit Coordinator Trauma Verification
What is the goal for this Webinar? Interpret the standards outlined in the Resources for Optimal Care of the Injured Patient manual to ensure that hospitals have an understanding of the criteria to provide quality care to the injured patient. Understand the processes and standards involved in an ACS Trauma Verification Site Visit and how following these will positively impact the quality of care of the injured patient at your center.
Let s get started!
Orange Resources Book If you have your Resources for Optimal Care of the Injured Patient 2014 (Orange Book) in hard copy or PDF version, it is recommended that you have it available to reference in the CD-Related Questions section of this webinar. The most current Clarification Document, and the Verification Change Log are available at: www.facs.org/qualityprograms/trauma/vrc/resources
Recording of Webinar The recording of this webinar will be posted on the ACS YouTube channel at a later date. All of our Resources are located on this webpage: https://www.facs.org/quality-programs/trauma/vrc/resources
Disclaimer All questions are pulled directly from the question submissions. There have been no edits made to the content and/or misspellings. If your question is not answered today, the question is either a duplicate or requires more information, and will receive a response from ACS staff within one week after the webinar. Any unanswered questions will be answered within one week after the webinar.
Scheduling
Site Visit: Consultation prior to Verification If you had a consultative review when you ask for verification review is the site responsible for addressing all deficiencies? And compiling with current orange book standards? (Level III Center) Yes. If during a consultation visit, the center was cited with criterion deficiencies (CD), it is expected that all CDs are addressed at the time of the verification visit. All CDs must be implemented, monitored and tracked through the performance improvement process with good outcome, at least 6 months prior to the verification visit.
Chart Review During chart preparation for VRC review--if a chart meets criteria for more than one category how do you manage? (Level I Center) Keep the chart in one category. Do not duplicate the chart. Tag/label it as a multi-system trauma injury.
Chart Review (Cont d) Do the charts for the reporting year go by admission date or discharge date of the patient? (Level I Center) Charts for the reporting year are based on the admission date.
Backup Call Schedules: Neurosurgery and Orthopaedic Surgery Are we required to have copies and/or access to back-up call schedules for Orthopedics and Neurosurgery? Or is it sufficient that they "tell" us they have a back-up call schedule? (Level II Center) Yes. During a site visit, the trauma center is required to demonstrate compliance with all standards. This will include documentation such as, call schedules, backup call schedules, trauma protocols, administrative commitment letters, etc.
General Questions
Webinar Responses Is there any way to "code" or "frame" requirements/questions/responses in the COT documents/webinars to be Level specific? (Level III Center) Yes. A data field was added to the webinar portal to capture the level of the trauma center that is asking the question. Moving forward, the webinar responses will be for that specific level.
PRQ Guide New! The Verification program has developed a PRQ guide to assist trauma centers in answering questions that are still pending IT programming revisions and/or clarifications.
PRQ-Challenges Where is the COT at in revising/fixing the PRQ? There were significant issues during our consult visit with the technology. (Level III Center) PRQ issues are being addressed on an ongoing basis. There are challenges to programming due to the complexity of the criteria based on the trauma center level and patient population.
PRQ Palliative Care Please clarify on the PRQ page 23 E. ICU #2 asking about palliative care. All pts or just trauma with palliative care? (Level II Center) With the exception of the Hospital Information section, all other responses in the PRQ should correspond to the trauma program.
PRQ-Appendices For Adult Level 1, Peds Level 2 Trauma Center, is it possible to add additional appendicies for pedi liaisons? (Level I Center) Great recommendation. We will take this into consideration. For the time being, we will provide the trauma centers with blank copies of additional appendices.
PRQ Combined Adult & Pediatric Programs For TCs that run their adult and peds PI separate (Adult L1,PedsL2), why no separate PRQ or more space for peds info? (Level I Center) Currently there is not a separate PRQ for pediatric programs. If the center is combined and is seeking separate verification, we have made revisions to the PRQ to incorporate the pediatric criteria. We can look into the areas of concern that may require additional space.
PRQ Combined Data For a combined survey, is the payor mix and other such fields a combo of all patients? Peds and Adults? (Level I Center) For centers that treat adult and pediatric patients, with the exception of Section II. Description/Trauma Levels and Roles, and Section X. Pediatric Surgery, all responses must be a combination of the adult and pediatric data. Section II include both adult and pediatric data. Section X include pediatric data only.
PRQ-Nurses If you have travel nurses do you count them in your percentages for "certified nurses" if they have that certification? (Level I Center) Yes. Include traveling nurses that hold a certificate in the data tables.
PRQ-Antibiotics Administered For patient transfers to us from OSH- Open fracture/ time to antibiotic administration-time given at our hospital or OSH time? (Level I Center) It is for antibiotics administered from the field or when patient is presented in the Emergency Department.
PRQ-FAST Exam Please elaborate on credentialing process and QI process of FAST exams? (Level II Center) The credentialing process will be defined by the hospital. How QI is done, will vary by trauma centers. For example, the center may uploaded the FAST exam to the EMR and review for accuracy, completeness, and technique. Feedback can be done by email or directly through the Q- path or other system.
Post-Traumatic Stress Disorder PTSD screening expectations pg 89 in orange book - Is this expectation during the acute care phase or the in-patient rehab phase? (Level III Center) There currently are no ACS standards for PTSD. However, the trauma center should develop guidelines on evaluating, treating, and managing patients with PTSD.
Classification of Dead on Arrival In reference to Dead on Arrival-the orange book provides the definition no additional resuscitation efforts initiated in the emergency department. Could you please provide some clarification regarding additional resuscitation efforts? Would continuing to provide ACLS and ACLS drugs be considered additional efforts, or continuation of efforts? For example, the patient lost pulses PTA and prehospital providers started CPR, administering ACLS drugs. Upon arrival to the hospital, CPR is continued and the patient is given another round of the ACLS drugs that were given PTA. At the next pulse check an ultrasound confirms no cardiac activity and the code is called. Would this patient be considered DOA, or would the drugs be considered additional resuscitation efforts? It would seem that intubation and insertion of chest tubes would be examples of additional resuscitative efforts, would this be correct? (Level II Center) Dead on arrival will vary from center to center. Defining DOA will be defined by the trauma center or state regulations.
TQIP-Benchmark Report In active pursuit of Level II: is it a deficiency to not have a TQIP report available during the site survey if you are enrolled? (Level II Center) Effective Jan 1, 2017, the requirement is for all trauma center to be enrolled in TQIP. If the center is fully enrolled in the program but has not yet received a benchmark report, the center will not be cited a deficiency for CD 15-5.
CD-Related Questions
Transfer Guidelines (CD 4-3) Regarding transfer agreements: As a regional trauma system we have developed a guideline outlining injuries appropriately care for at our Level IV and Level II facilities. Patients with injuries above their level will be transferred to the appropriate trauma center. With this in place is there still a need for written agreements that state our Level II facility will accept trauma patients? (Level II Center) If the regional transfer agreement includes the names of the trauma centers along with the types of injuries that will be transferred and/or received, that will be acceptable.
ATLS for General Surgeons (CD 6-9) Please confirm: General surgeons on the trauma call panel all have to have taken ATLS once, but only the TPM needs to be current. (Level II Center) General surgeons must have completed the ATLS course at least once. They are not required to be current. The TPM is not required to have ATLS. Advanced Practice Providers who respond and participate in codes/activations, must be current in ATLS (CD 11-86).
Emergency Medicine (CDs 7-14 and 7-15) Do ED providers need current ATLS or have taken it only once? (Level II Center) CD 7-14, physicians who are board certified or eligible in Emergency Medicine and work in the Emergency Department, must have taken ATLS at least once. CD 7-15, physicians who are board certified or eligible in something other than Emergency Medicine, such as, Internal Medicine, Family Practice, etc., and work in the Emergency Department, must be current in ATLS.
Response Times: Neurosurgeons (CD 8-2) and Orthopaedic Surgeons (CD 9-7) Do trauma surgeons count for the 30 min rule for specific neurosurgery and orthopedic surgery patients? (Level II Center) No. The expectation is for the specialists or Advanced Practice Providers (APPs)/residents* for that service to respond when the request is made by the attending surgeon. *There must be guidelines for the types of injures the APPs will respond to, and have clear documentation with the attending specialist surgeon on the plan of care.
Neurosurgery-Chapter 8 Is neurosurgical backup call schedule required or is contingency plan ok for level 2? (Level II Center) Must have a published neurotrauma call schedule with formally arranged contingency plans (CD 8 3). Best method is having a backup call schedule. If no backup call schedule, must have a contingency plan (CD 8-5) Plan is formalized, and can include training/credentialing with trauma surgeons for initial stabilization. Transfer to another center of same/higher level. Must be monitored by PIPS.
Neurosurgery-Chapter 8 (Cont d) Level I, II and III trauma center: If one neurosurgeon covers two centers within the same limited geographic area, there must be a published backup schedule (CD 8-6). In addition, the performance improvement process must demonstrate that appropriate and timely care is provided (CD 8 6).
Examples of 30 minute response time patients Neurosurgery Penetrating injury to head with altered mental status TBI with emergent surgical intervention TBI with emergent EVD monitoring Orthopaedic Surgery Fracture with vascular compromise Complex pelvic injuries with limb / life threat Multiple open long bone fractures
Orthopaedic Operating Room Cases (CD 9-3) For CD 9-3, does this only apply to emergent orthopedic cases or all orthopedic cases? (Level un-identified) In Level I and II trauma centers, a system must be organized so that musculoskeletal trauma cases can be scheduled without undue delay and not at inappropriate hours that might conflict with more urgent surgery or other elective procedures (CD 9 3). Applicable to all Orthopaedic cases.
Anesthesia Services (CDs 11-4 and 11-5) For Level 2 centers, is a CRNA in house and Anesthesiologist present within 30 minutes sufficient? (Level II Center) Yes. The in-house Anesthesia requirements may be fulfilled by senior residents or CRNAs or Certified Anesthesiologist s Assistants (C-AA). The Anesthesiologist has 30 minutes to respond from the time notified.
Operating Room Team (CD 11-14) Is the in house OR crew a requirement? (Level II Center) An operating room (OR) must be adequately staffed and available within 15 minutes at Level I and II trauma centers (CD 11 14). The best method to meet this time requirement is by having the OR team in-house. If tracking the response times for each of the team member from outside the hospital, you must demonstrate that the response time of 15 minutes is met all the time. There is no variance for this.
ICU Coverage (CD 11-60) Provide example to meet the criteria requiring trauma to monitor ICU response times. (Other than intensivist in house 24/7) (Level II Center) For all levels, the PIPS program must document that timely, and appropriate ICU care and coverage are being provided (CD 11 60). Coverage can be met with the trauma surgeon, Intensivists or PGY 4 or 5 residents.
ICU (CD 11-64) What is the requirement for Level 2 centers for Intensivist coverage? Do they need to be in house 24 hr / day. Telemedicine? (Level II Center) There are no standards specific to Intensivists. However, if they are used to provide coverage for trauma patients in the ICU, they are expected to meet the same standards as the other surgeons, e.g. participate in an internal education program that is case based learning or obtain 16 hours of CME.
Other Specialists (CD 11-70) What are the requirement s for Level II and OB? And if you do not have in house OB services? (Level II Center) Level II trauma centers must have available obstetric and gynecologic surgery (CD 11 70). Develop guidelines with a plan of care for the mother and the unborn child, including impending delivery: Utilize OB & NICU as part of the trauma team Specialized equipment Consider transfer agreements for services not available
Advanced Practice Provider (CD 11-86) Can a non-atls physician extender participate in the care of an injured patient? Also, can they complete the initial assessment of an injured patient? (Level un-identified) Yes. To clarify, the Trauma or Emergency Medicine Advanced Practice Providers (APPs) can provide assessment to non-trauma activations such as the consultation tier or fast-track. Neurosurgery and Orthopaedic Surgery APPs can respond when consulted by the attending surgeon during an activation.
Social Services (CD 12-2) As Social Services must be available at all times, is it required that there be a person assigned only to the Trauma service? (Level II Center) No. The types and numbers of trauma program support staff vary from center to center. This role can be shared within the hospital system.
TQIP Requirement (CD 15-5) and Fees TQIP requirements and fees for Level III Trauma facilities. (Level III Center) Effective January 1, 2017, all trauma centers seeking re- /verification must be enrolled in TQIP (CD 15-5). The base fee for hospitals participating in the Trauma Quality Program (VRC+TQIP) will be $12,000 for Level III Centers. - Additional Fees for additional reviewers - More details on our website.
TQIP Level III (CD 15-5) By what point would a Level III facility in the process of going to Level II begin to submit to TQIP? A center not currently enrolled in TQIP should join the TQIP program appropriate to the level of verification they have applied for. In this case, the hospital should join Level I&II TQIP. If you have submitted an application for an ACS consultative or verification visit, you are eligible to begin the process of joining TQIP. Once your hospitals has joined TQIP, (signed the appropriate agreements and paid the fee,) you will be able to submit data. If the center is fully enrolled in the program but has not yet received a benchmark report, the center will not be cited a deficiency for CD 15-5.
Injury Prevention Coordinator (CD 18-2) We are a hospital within a hospital. We are an adult level 1 and peds level 2. We have an injury prevention outreach department. does the leadership over injury prevention have to be someone from the trauma office we integrate all services with them? Yes. The injury prevention coordinator can be part of a hospital injury prevention department; however, there must be someone assigned to trauma.
Alcohol Screening (CD 18-3) For SBIRT we use both a screening questionnaire and blood alcohol. If the questionnaire scores positive or the BAL meets a threshold a BI is ordered. Both the questionnaire and BAL is not always completed on all patients. To meet the requirement to screen 100% of NTDS patients; do we have to have both the questionnaire and the BAL completed to count the screening as done or can we count as done if at least one of the screening methods (questionnaire or BAL) is done? (Level I Center) If the hospital protocol require use of both screening tools, those patients that are not screened, must be reviewed through the PIPS process.
Research (CDs 19-3, 19-4, and 19-7) Does being an author on a book chapter count towards one of the required papers for research? (Level I Center) Yes, an author on a book chapter is acceptable as long as the author s name is published.
Interventional Radiology (CD 11-33) What is the expected response time for intervention Radiologist? Is it tracked from time of written order or verbal no. (Level I Center) The response time is tracked from when the call is made requesting the service.
Multidisciplinary Trauma Peer Review For monthly meetings, a representative from administration is required - does it matter which administrator is present? (Level II Center) There is no requirement for a representative from the hospital administration to attend the peer review meeting. Aside from the required attendees, additional staff may attend at the discretion of the trauma medical director and/or trauma program manager.
Multidisciplinary Trauma Peer Review-(Cont d) Has there been clarification on an alternate representative to the designated trauma liaison when he/she cannot make it to mtgs? (Level I Center) Yes. The attendance to the peer review meetings can be met by the respective liaison or a designated representative. The designated representative must be the same person at the monthly meetings. This change does not apply to the trauma medical director or trauma surgeons.
Continuing Medical Education (CME) If a MD is "board eligible" are they exempt from the CME requirement? For example a new Orthopod or GS/CC Attending. (Level I Center) If there is a new hire to the service or just completed residency, their CMEs will be prorated.
CME (Cont d) Could we get some Level III CME Clarification? I thought TMD s at LIII Centers needed 16hrs/1yr 48hrs/3yrs. I see this in the most recent clarification doc: One of the challenges in listening to the Webinars is that not each slide is applicable to each level, but it can be difficult to interpret who is being spoken to. I feel like it would be helpful to many to do a simple CME Grid for the different Levels, something like this (Not that this is correct, I am clearly confused. Great recommendation, tables will be provided at the end of this presentation. As mentioned earlier, I will direct my responses to the specific level to avoid confusion.
Internal Education Process (IEP) Please comment on what types of internal education meet IEP standards. (Level I Center) The following 3 slides will provide an overview of IEPs that may be used. The Committee on Trauma s Information Technology Committee developed and launched, a survey to capture how trauma centers are doing IEP. Responses will be collated and compiled in the hopes of developing a best practices guideline and/or resource.
IEP: Should Reflect Topics Based On: Quality issues identified in your peer review, systems meetings, nursing & physician chart audits. Based on regulatory mandates: joint commission, pain assessment, falls, medication, VAP. Evidence based practice through journal or national meeting information. Case based learning that identifies issues through the PIPS. Must be able to document the activity. Approved by TMD. Should be quarterly, at a minimum, and functionally equivalent to 16 hours of CME verifiable by provider.
Internal Education Program What does it look like? In-service, case-based learning; educational conferences; grand rounds; internal trauma symposia; and in-house publications disseminating information gained from a local conference or an individual s recent participation (through trained analysis) reviewing a trauma center. Does not require CME s. Attendance/communication of information must be documented.
IEP Checklist Determine what platform or program will be used to document and capture the IEP. Sharepoint, SurveyMonkey, Intranet Define the subject matter. Conferences: local, regional or national Peer Review articles, Webinar, Courses How often is the IEP utilized? Weekly, Bi-Monthly, Monthly, Quarterly, Bi- Annually, Annually Must track participation from the members. Ability to present the hospital s IEP for the site reviewers.
TMD & Liaison/Representative Criteria 50% may include liaison and/or liaison representative from specialty [1] Refer to CD 7-14, physicians boarded/board eligible in Emergency Medicine, taken once [2] Refer to CD 7-15, physicians boarded/board eligible in Family Practice, Internal Medicine, etc., must be current
Other Trauma Panel Members [1] Refer to CD 7-14, physicians boarded/board eligible in Emergency Medicine, taken once [2] Refer to CD 7-15, physicians boarded/board eligible in Family Practice, Internal Medicine, etc., must be current
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