May 4, 2018 The Honorable Lamar Alexander Chairman Senate Committee on Health, Education, Labor and Pensions United States Senate 428 Dirksen Senate Office Building Washington, DC20510 The Honorable Patty Murray Ranking Member Senate Committee on Health, Education, Labor, and Pensions United States Senate 835 Hart Senate Office Building Washington, DC 20510 Dear Chairman Alexander and Ranking Member Murray: On behalf of the more than 80,000 members of the American College of Surgeons (ACS), we would like to thank the members of the Senate Health, Education, Labor, and Pensions (HELP) Committee for the Pandemic and All Hazards Preparedness and Advancing Innovation Act of 2018 (PAHPA) discussion draft. The ACS strongly supports strengthening our nation s trauma care system and looks forward to partnering with Congress as this legislation works its way through the legislative process. We appreciate this opportunity to share some of ACS thoughts on how PAHPA can be further enhanced to fully meet the needs of any disaster and provide a framework to ensure all injured patients receive the highest-quality health care. The ACS Committee on Trauma (COT) was formed in 1922 and has made continuous efforts to improve care of injured patients in our society. Today, our trauma activities are administered through an 83-member Committee, overseeing a field force of more than 3,500 ACS members nationwide who are working to develop and implement meaningful programs for trauma care in local, regional, national, and international arenas. In addition to being a major public health problem, costs related to trauma rank as the second most costly condition in America, totaling over $670 billion in 2013. This includes medical expenses, lost wages, and lost productivity. Accordingly, we believe that improving access to trauma care for all Americans will yield immense returns via efficiencies of scale within public health and safety and in overall health care expenditures.
To assist with the development of a national framework for trauma care and to address some of the shortfalls in our current trauma system, the ACS asks the following legislative proposals be included in the 2018 PAHPA reauthorization. The Mission Zero Act: Building upon the legislative framework passed in the fiscal year (FY) 2017 National Defense Authorization Act (NDAA) and further incorporating military trauma care providers into the civilian setting. These military-civilian trauma care partnerships will increase military health care readiness and provide high-quality trauma care both domestically and abroad. Authorization of Trauma Care Programs to Ensure Preparedness: Establishing a national trauma system capable of providing the best trauma care to anyone injured in the United States within one hour of injury. Creating a unified framework for trauma care will ensure that regardless of where a patient is injured, they will have the best chance of survival. The Good Samaritan Health Professionals Act: Ensuring medical providers have appropriate medical liability coverage when volunteering during a federally-declared disaster. When disaster strikes, this legislation will assist in removing barriers that exist for health care volunteers looking to provide care across state lines. Guidelines for Trauma Care: Through setting standards and establishing guidelines for trauma care, there can be a better utilization of trauma-related data tracking and designation of trauma centers based on system need. The Mission Zero Act It has been a priority for the ACS to work toward the establishment and maintenance of high-quality and adequately-funded trauma systems throughout the United States, including within the Armed Forces. In 2014, the ACS formalized a partnership with the Department of Defense (DoD) Military Health System (MHS) to exchange information and incorporate best practices from both civilian and military health systems. The partnership was charged with the following goals to share information related to: Enhancing the curriculum used to teach military surgical skills through expansion of the ACS Advanced Surgical Skills for Exposure in Trauma course and other programs. Updating existing education offerings of importance to military and surgical communities that are interested in humanitarian and disaster response. Validating the military s Optimal Resources handbook.
Developing ways to increase the involvement of military surgeons in the ACS senior leadership program. Reviewing of the DoD Combat Casualty Care Research Program. Developing relevant research portfolios, including research conducted through the ACS National Trauma Data Bank and Trauma Quality Improvement Program. Creating a systems-based practice, including surgical clinical practice guidelines and development of an optimal resources manual for surgical care. Through this partnership, ACS has increased the capability of military trauma health care to develop a well-rounded and comprehensively trained military/civilian trauma surgeon. One of the prime examples of civilian health care advancements derived from the battlefield is the use of tourniquets. Through experience gained in the wars in Iraq and Afghanistan, the military determined that improvised tourniquets were not the most effective, and subsequently came to promote the use of combat application tourniquets (CAT). When translated to the civilian sector, this advancement prompted both medical first responders and bystanders to use tourniquets to save life and limb during the Boston Marathon bombing and other mass casualty events. To further build upon military-civilian partnerships and the sharing of lessons learned, ACS supports inclusion of the Mission Zero Act (H.R. 880/S. 1022) in PAHPA reauthorization. The Mission Zero Act would provide grant funding through the Department of Health and Human Services (HHS) to facilitate partnerships between military trauma care teams/providers and high-volume civilian trauma facilities. These partnerships in turn would allow military trauma care teams/providers to gain exposure treating critically injured patients and increase readiness. Valuable lessons have been learned through the exchange of information between the military and civilian trauma care communities, but more are yet to be derived. Increasing military civilian partnerships is also a critical step toward achieving the goal of zero preventable injury deaths as highlighted in the June of 2016 National Academy of Sciences, Engineering and Medicine (NASEM) entitled, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. The creation of a grant program to assist civilian trauma centers in partnering with military trauma professionals establishes a pathway to provide patients with the highest quality of trauma care in times of both peace and war by assuring that our military medical corps is kept in a constant state of readiness for deployment to conflicts, humanitarian needs, or to natural/man-made disasters. Incorporation
of the Mission Zero Act in PAHPA would further strengthen the quality of trauma care within the civilian and military realms and ensure our military maintains a state of health care readiness. Authorization of Trauma Care Programs to Ensure Preparedness We applaud the Committee for highlighting the critical issue of improving our trauma care system by including placeholder language regarding trauma system development. ACS is hopeful that this placeholder section will ultimately contain language that will lead to the development of a national trauma system. Trauma systems have been organized across the country to manage the timesensitive crises of acutely injured patients in an efficient manner on a daily basis. Trauma systems span the continuum of care from the point of injury through rehabilitation. As a result, these systems engage in numerous activities aimed at improving care and outcomes, including bystander training, emergency medical services (EMS) training and coordination, hospital preparedness, and continuous quality improvement. Nationally, there are examples of strong state and regional trauma systems. However, there is significant variability between these systems which creates a patchwork approach to regionalized trauma care. While there have been dramatic advancements in trauma care, the lack of clear and uniform standards for trauma system infrastructure has led to significant variability among trauma systems based on available resources, geography, and local leadership. The NASEM report from June of 2016 is the sixth such report over the last 50 years to address the need for a national approach to trauma care. While criteria for optimal elements of trauma systems have been identified and subsequently evolved, the adoption of such standards and their implementation has been entirely voluntary for states and regions. Without federal oversight and sustainable financial support, many systems lack the infrastructure and authority needed to ensure that the appropriate resources are in place from point of injury through rehabilitation. These goals can be achieved by renewing, through 2023, the authorization of the trauma and emergency care grant programs contained in Public Health Service Act Sections 1201-04, 1211-22, 1241-46 and 1281-2. ACS appreciates the opportunity to have previously worked with the Committee on the development of parameters surrounding trauma system development and we look forward to further discussions.
The Good Samaritan Health Professionals Act ACS was pleased to see that enhancements to the National Disaster Medical System (NDMS) are included in the PAHPA discussion draft. The current NDMS has proven to be burdensome, slow, and ineffective for providers. While the NDMS is a step in the right direction, more can be done to address the issues and barriers surrounding health care providers volunteering during federally-declared disasters. Medical professionals have a history of eagerly stepping forward to volunteer when disaster strikes. Unfortunately, far too many providers are hindered by liability concerns. Despite its intent, the Volunteer Protection Act (VPA) fails to address such concerns. During Hurricane Katrina, in August of 2005, health care providers were tasked with menial jobs, such as mopping floors instead of practicing medicine. This was due to vague laws surrounding licensure and liability coverage. This is not an ideal use of volunteer resources and hinders patient care. ACS believes that inclusion of the Good Samaritan Health Professionals Act (H.R. 1876/S. 781) in PAHPA would remove barriers and ease liability concerns that often prevent health care providers from volunteering their services during a federally-declared disaster. The Good Samaritan Health Professionals Act would address the shortfalls in the VPA and make it easier for appropriately-licensed providers to cross state lines during a federallydeclared disaster and do so without fear of liability concerns by enabling liability coverage to follow the provider across state lines while not preempting any current state law or licensure. Inclusion of legislation that would reduce barriers for health care providers looking to volunteer during a federally-declared disaster, such as the Good Samaritan Health Professionals Act, will greatly decrease loss of life as well as improve outcomes during public health emergencies. Guidelines for Trauma Care The ACS COT has a long history of, and experience with, the verification of trauma centers across the country to ensure that hospitals meet the criteria contained in Resources for Optimal Care of the Injured Patient. The ACS COT typically works with a designation authority in states to complete this process. While trauma center designation is left appropriately to state regulation, all too often state agencies lack the statutory authority and political support to make difficult decisions. As a result, there are inappropriate designations of trauma facilities in areas where they are not needed and too few in areas where they are lacking. In August of 2015, the ACS COT convened a panel of medical and
trauma stakeholders from across a broad spectrum of roles, to establish consensus around the principle that designation of trauma centers should be based on need. As the Committee examines guidelines and criteria necessary for responding to wide scale needs, ACS suggests examining the way trauma centers are designated and distributed. The ACS welcomes the effort in the current draft to identify and disseminate guidelines for regional resources to treat patients and increase medical surge capacity during a public health emergency. Regional trauma system implementation has been shown to improve mortality and reduce complications. The number, level, and location of trauma centers are critical elements of trauma system function and disaster response. We believe this is especially critical during public health emergencies such as, biological, radiological, and nuclear events. ACS also believes that regional trauma systems should be planned in order to optimally meet the need of the local population in the region. Therefore, trauma center designation should be guided by a regional trauma plan based upon the needs of the population being served. Trauma system needs should be assessed using measures of trauma system access, quality of patient care, population mortality rates, and trauma system efficiency, such as the number of Level I and Level II centers per 1,000,000 population, the percentage of the population who have access to a Level I or II center in less than an hour following injury, and the percentages of time trauma centers are on diversion status. We agree with the requirement instructing the Assistant Secretary to consult with health care facilities, trauma care providers, and others in developing guidelines. We suggest the addition of accrediting and verification bodies as they are especially well versed in evaluating the capabilities of trauma centers and identifying potential gaps in resources. The ACS also asks this Committee to adopt language reflective of the COT recommendations relative to how trauma centers are designated. Establishing legislative guidelines to ensure trauma systems are structured in a way that serves the needs of the population and provides a stable system framework that is not subject to variations in the health care market. In addition, given that trauma centers serve as critical infrastructure for disaster response, we suggest that language be adopted that requires engagement of trauma centers in the state and regional planning processes overseen by the health care coalitions supported by the Assistant Secretary for Preparedness and Response (ASPR). We also support the inclusion of a GAO report to Congress to provide data on the preparedness and response capabilities on these guidelines. However, we feel that the timeline for implementation and this report are too compressed for
a meaningful evaluation. As drafted, guidelines are to be identified, developed and published not later than one year after the date of enactment and the GAO Report to Congress is to be submitted not later than two years after enactment. This means that GAO would be evaluating uptake of the guidelines before adequate time has been allotted. We suggest that the report be delayed by at least six months to allow a full year for implementation prior to evaluation to ensure that it is meaningful. ACS Trauma Quality Improvement Program (TQIP) is a landmark program that works to elevate the quality of trauma care through data. Through the use of TQIP, evidence-based journals and experts in the field, TQIP Best Practices Guidelines are established that work to improve trauma care nation-wide. The measuring and recording of data is a cornerstone of advancing not only trauma care, but health care as a whole. Through the interpretation of trauma data, we can identify key characteristics at a facility that will help to improve patient outcomes on a global scale. ACS requests that the Committee will consider acknowledging data participation as a guideline for trauma care. Conclusion Thank you again for the opportunity to provide feedback to the PAHPA draft document. ACS believes that enhancing military-civilian trauma care partnerships, renewing the authorization of trauma care grants, minimizing trauma-related medical liability concerns for federally-declared disaster volunteer health providers, creating robust guidelines for trauma systems, and harnessing available data to improve trauma care for the injured patient will positively impact our nation s preparedness and ensure that our trauma system is able to meet the needs of all Americans. We stand ready to work with Congress as the PAHPA reauthorization continues to advance through the legislative process. Sincerely, David B. Hoyt, MD, FACS Executive Director, ACS