TRAUMA SYSTEM AND TRAUMA CENTER ORGANIZATION

Trauma Center Organization

The development and success of a trauma center is contingent upon two basic building blocks: hospital organizational support and medical staff support. First, the hospital and its leadership must have a firm administrative and financial commitment to trauma center development, including incorporating the program into the formal organizational structure at a point commensurate with other clinical care departments of equal organizational stature. Second, medical staff support must be adequate for all levels and types of trauma patient care.⁶ The basic organizational structure schematic is shown in Figure 1.

Figure 1 Trauma center organizational structure.

The core elements of a trauma center include the trauma team, the trauma service, and the trauma program, which has the overarching responsibility for the entire trauma center. The trauma team is the provider and ancillary support that responds to emergency department trauma activations.

Levels of response are guided by patient acuity and level of trauma center resources. Higher patient acuity with more robust resources, as in Level I and II trauma centers, encumbers response from the general/trauma surgeon, emergency physician, anesthesia provider, resident trainees, trauma/emergency nursing, respiratory therapy, radiology technician, security, and religious counsel. The team leader is the surgeon who is ultimately responsible for the patient’s disposition and care, but more importantly, all members of the team work together to streamline patient care according to Advanced Trauma Life Support® guidelines. The trauma service maintains the clinical responsibility for continuity of care in the multidisciplinary environment of injury care. In higher-echelon trauma centers, the trauma service is often a formal clinical service or services under the guidance of trauma staff surgeons. In Level II facilities, these trauma patients are often admitted to the primary surgeon of record and the continuity and oversight to maintain service integrity are provided by the trauma medical director.

The trauma program within a trauma center is a multidisciplinary effort that supports injury care from resuscitation through rehabilitation. Integral staff elements within the trauma program are the trauma medical director, trauma staff, physician specialty staff (orthopedics, neurosurgery, emergency medicine, anesthesia, radiology), trauma program manager/trauma nurse coordinator(s), and trauma registrar(s).⁶ The key processes that distinguish a trauma center are performance improvement and multidisciplinary peer review.

Trauma Medical Director

The trauma medical director is usually a general surgeon with a specified interest or specialty training in trauma who functions as the key leader within the trauma medical staff. The trauma medical director should be learned in the field and proficient in the technical skills of the profession. More importantly, this individual should have authority over all aspects of the trauma program, including the development, alteration, and implementation of clinical practice guidelines; coordinating trauma and trauma specialty services; performance improvement monitoring and outcomes assessment; and providing strategic planning guidance for the program. Less tangible, although no less vital, requirements of this position include administrative and committee responsibility and team building responsibilities.

Trauma Program Manager/Trauma Nurse Coordinator

The position of trauma program manager and trauma nurse coordinator are dual positions or can be coalesced into a single position depending on the size and volume of the trauma program. This position is filled by a highly specialized registered nurse with advanced trauma training who is integral to the development, coordination, implementation, and evaluation of trauma care within the program. This position serves as a key leadership liaison between the staff and process elements within the program (Table 1).

Table 1 Roles of Trauma Program Manager/Trauma Nurse Coordinator

Role	Definition
Clinical	Coordinating continuity and quality of trauma care in multidisciplinary environment
Administrative	Helps manage the operational and fiscal activities of the program as well as participates in various committee activities
Leadership liaison	Team building
	Promotes trauma program at local, regional, state, and national levels
Educational	Trains trauma program staff
	Provides resource plan to train local facilities
	Promotes outreach programs
Registry	Oversight of trauma registry data collection and accuracy
Performance improvement	Key proponent of trauma program performance improvement process from discovery through loop closure
Research	Promotes accurate and reliable data collection and analysis for performance improvement and facilitates clinical research endeavors
System advocate	Trauma system development, funding, patient advocate, injury prevention, public education, and outreach

Trauma Registrar

Trauma registry personnel are required in trauma programs on the basis of allocation of one registrar for every 500–1000 trauma admissions per year. The goal of maintaining such a record is to have a repository of trauma patient data that can be used for trauma program performance improvement or can be evaluated alone or in conjunction with other trauma registry databases in order to answer public health questions or provide trauma outcomes analysis. Registry databases are collected in standardized products to facilitate analysis and transfer of information between institutions, and to state and national repositories. Data are coded in standard formats and de-identified prior to analysis to safeguard individuals’ protected health information.

TRAUMA PERFORMANCE IMPROVEMENT PROCESS

The trauma performance improvement process is perhaps the most important of all trauma program processes for ensuring that the highest quality of care is rendered to each injured patient. The importance of this process is vital from a functional and verification perspective. In fact, more than 50% of verification visit time is spent evaluating patient records and performance improvement. Trauma performance improvement begins with the definition of trauma (ICD-9 codes 800–959.9). This process is based on the tenets of program monitoring, which should be contemporary and based on reliable data. Outliers are identified that serve as indicators of deviation from the standard of care which require further review and discussion. A decision must be made as to whether no action is required or corrective action needs to be instituted in the form of individual counseling, education, policy review, peer review, or multidisciplinary trauma committee review. Once the corrective action has been implemented, the performance indicator returns to the monitoring phase. If performance measures are acceptable, the “loop” is closed (Figure 2).

Figure 2 Performance improvement loop closure.

Performance improvement measures can be categorized as process or outcome measures. Some commonly assessed performance measures follow:

From the outcome perspective, frequently evaluated outcome measures include hospital and ICU length of stay, morbidity, and mortality. In particular, all trauma mortalities require review within the performance improvement process and each death classified as to whether it was preventable, possibly preventable, or nonpreventable.

TRAUMA CENTER VERIFICATION

The basic premise for trauma center verification is to ascertain whether a trauma center meets the guidelines outlined in the Resources for the Optimal Care of the Injured Patient published by the American College of Surgeons Committee on Trauma. Trauma center designation is a process that is geopolitical in origin, and is the ultimate responsibility of the local, regional, or state health care agency with which the trauma center is affiliated. In some states, trauma center designation tasks the regional provision of trauma care to particular hospital facilities, and is required to receive uncompensated care funding from governmental agencies and apply for governmental research grants and support. The designation and verification processes are complementary: designation recognizes capability, whereas verification confirms adherence to established guidelines. Effective trauma centers require both processes to affirm institutional and governmental commitment to the success of the trauma program.⁷

The verification visit is contingent on approval by the responsible designating authority or in the absence of such an agency, upon request of an individual hospital. Once this occurs, the facility completes the verification application for a site visit followed by completion of pre-review questionnaire (PRQ). A review team is selected, the composition of which may be dependent on the requirements of the designating authority. The verification review consists of a pre-review dinner meeting and an on-site review characterized by a tour of the facility followed by an in-depth chart review and performance improvement process analysis. Other aspects of the trauma program, including prevention, prehospital care, trauma service organization, educational activities, and rehabilitation programs are also evaluated. Trauma center criteria are shown in Table 2.

Table 2 Trauma Facilities Criteria

a Answers to FAQs can be viewed on the American College of Surgeons website at www.facs.org/trauma/faq_answers.html. FAQ, Frequently asked questions; PIPS, performance improvement and patient safety.

Source: Adapted from Committee on Trauma, American College of Surgeons, Resources for Optimal Care of the Injured Patient: 2006, 5th ed. Chicago, American College of Surgeons, 2006, Chapter 16, pp. 139–141.

The preparation for verification and the verification process itself have demonstrated significant impact on trauma patient care and lowering of injury mortality.^8–10