March 16, 2008

Dr. Fildes opened the meeting with the following announcement.

The 2008 Annual Meeting will be held in Washington, DC on March 13th -15th. COT members will be invited to arrive in advance to attend a training session given by the ACS Advocacy staff the morning of Wednesday, March 12th. After the training, members will visit the offices of their local legislators.

Report of the Medical Director, Dr. Meredith

The Board of Regents approved all three action items proposed by the COT. The business plan to move ATOM into the COT was approved, and now a structure will be needed to support the course. The Board of Regents also approved some liaisons with other organizations. Additional members will include two burn and one urologic surgeon.

The Board of Regents is going through a strategic planning process aimed at better serving the fellows. Several efforts are underway. One is partnering with the Harvard School of Public Health to form a health policy institute at the new location being built on F Street. A PR firm, Weber Shandwick, has been hired to help increase awareness of the ACS amongst the general public and policymakers as a source of rational information and policy advice. Weber Shandwick has a well-designed plan, and one in which Trauma spearheads the message to the public. This has lead to the work of the COT being better recognized by the College leadership as well as the public.

The plan given to the Board of Governors looks at public perceptions and identifying the correct audiences. A political active target group has been identified through surveys. According to those surveys, the ACS appears to them as skilled experts, innovators in new technologies, and people who save lives. There are also some negative impressions in need of change, such as appearing arrogant.

The strategy is to move on the fact that the COT members are innovators and engage the public and policymakers to recognize what surgery does, that is good for them. The ACS will take that platform, and then move on to workforce shortages, liability and reimbursement issues.

Report of the Subcommittees

Education, Dr. Rotondo for Dr. Spain

Dr. Rotondo announced the sessions for next year’s Clinical Congress;

• Good Trauma Care under Difficult Conditions, headed by Drs. Rotondo and Foley, with Dr. Johannigman as alternate.
• Improving Trauma Care in the Developing World, headed by Dr. Mock and with Dr. Price as alternate.

The Education Committee is now prepared to submit two names for next year’s Scudder Oration.

Publications, Dr. Ford

The committee is actively working on about eight posters, with extensive progress to date. The next format for most posters will be live and interactive on the web, and will include streaming videos. The committee expects to present at least three, almost ready for publication, to the Executive Committee at the next meeting.

The Trauma Video Session is scheduled for Wednesday at 1:00 pm, and COT members are encouraged to attend.

Dr. Fildes added that he’s had the opportunity to see the new posters, which have radiologic images, algorithms, and links to additional text.

Emergency Services/Prehospital, Dr. Salomone

Work was continued on the pediatric traumatic arrest evidence-based review.

The committee sponsored the general session following the Scudder Oration, on Controversies in Trauma Triage and Resuscitation. Half of the session is devoted to discussing drug-assisted intubation in the fields, then a point/counterpoint between Drs. Hoyt and Bulger, and a discussion by Drs. Hunt and Jurkovich of the field triage criteria.

One new project is development of a pediatric ambulance equipment list in response to a problem identified in the IOM report. The group also voted to support a new field triage scheme for mass casualty/disasters. They will begin developing some air medical transport guidelines for trauma patients as well.

Liaison reports:

• The new president at ACEP will be working on physician reimbursement and ED overcrowding.
• NHTSA is developing new educational standards for all levels of EMS providers across the country.
• The CDC has developed and shown the committee some PowerPoint slides and posters on bomb and blast injuries.
• EMS for Children has approved nine grants, of up to $200,000 each, some dealing with trauma care and outcome, some in the prehospital setting.
• PHTLS trained over 30,000 people in the last year in over 2100 courses. 500,000 providers have been trained since the program’s inception. The new manual has sold over 37,000 copies in a year, including 5000 military editions. Germany and Poland have been added to the PHTLS international family, with Lithuania to be added next month.

Injury Prevention and Control, Dr. Schermer

The committee has worked very hard on the SBI project. More than 400 people have been trained to date. SAMHSA and the CDC will probably have funding in 2008 to continue and do supplemental trainings. The billing and coding category was approved last spring. The committee is putting together a packet on how to approach your state about SBI.

Dr. Kappel and a subgroup have finalized a position statement on ATV legislation issues, which will be presented to the Executive Committee, to take to the next Board of Regents Meeting.

In addition, they are hoping to get more support for the federal repeal of UPPL.

The National Safety Council Award was narrowed down to three finalists today, who will be presented to the Executive Committee.

Drs. Kuhls and Sise will head a collaborative effort with EAST and AAST to develop a suicide prevention packet.

NTDB, Dr. Clark

NTDB continues to grow at a rapid pace with almost half a million records a year added. The report from this year is on time and available, both pediatric and overall. NTDB continues to get data requests from researchers and publications.

One of the big events of the coming year is the adoption and implementation of the National Trauma Data Standard. Data submitted in different formats has led to problems. Hospitals will be required to submit data that can be mapped into this format this year, and next year only this format will be accepted. This may result in fewer records, but higher quality.

The CDC is supporting the National Sample Project, which is trying to get national estimates of trauma center patients.

The committee is looking at the problems involved with inter-hospital comparisons, which is reflected by the graphs and tables in this year’s report.

In addition to support from the CDC, NHTSA and HRSA, the AHRQ has now also gotten involved with and funded two projects using NTDB data.

The TQIP project is being supported by members and staff, and will be in a general session with various other college data programs this Wednesday.

PIPS, Dr. Cryer

The goal of the PIPS committee is collaboration with NSQIP and the Outcomes, NTDB and VRC committees to develop a comprehensive and standardized performance and safety program that can measure and enhance patient care on a national basis. Also, to provide a practical best practice manual for trauma centers.

Dr.Tinkoff is leading a group that works with STN members on revising the web-based instruction manual. It will include information from the Resource document, the current web manual and slides from the current STN course manual.

They are also involved in development of standardized process measurement tools linked to individual complications.

The committee is working with the TQIP national benchmarking project.

They have identified the ideal components of a PIPS plan;

• An accurate regional/national clinical database
• Identification of risk factors
• Accurate measurement of complications
• Risk-adjusted outcomes measurement
• Identification of best practices
• Evidence-based guidelines
• Benchmarking
• National and regional monitoring and feedback

Structure already in place includes:

• The Resource document and web manual
• The VRC committee, to validate data and outcomes
• ATLS and ATOM providing instruction on best practices and processes
• NTDB

The committee has learned that quality trauma care is about systems as well as personal performance.

They expect TQIP to decrease variability in care and outcomes nationwide.

The committee has rough drafts on six or seven measurement tools for identification of processes of care, and is working on the rest.

Dr. Shafi presented a project at the AAST meeting; a risk-adjusted analysis of all ACS verified Level I centers with 1000 or more patients a year, in which he found variability even across ACS verified centers.

Drs. Glance, Ostler and colleagues have been awarded an AHRQ grant for over a million a year to develop a new risk adjustment model. COT members will be asked to participate in a study to see if it improves care and identifies best practices.

This is just part of the whole TQIP proposal given to the Regents, to improve NTDB accuracy, update risk adjustment, develop a benchmarked report card, and site visits to determine best practices in pilot studies, which will all be rolled out over time.

ATLS, Dr. Kaufmann reporting for Dr. Kortbeek

The 8th edition of ATLS will be on time and will be available for October’s meeting. The sample pages have already been given to the Executive Committee. It will be in color from this point forward.

Last March the committee approved the mannequin manufactured by Symbone of Switzerland, and they are very happy to have competition between two manufacturers now. There is potential for additional competition from a company in the UK as well.

The entire network of the web-based course management system has been rolled out through the US, Canada and countries that sponsor ATLS through ACS chapters.

Will Chapleau was congratulated on the fact that all ATLS student and faculty histories are now up to date.

State chairs and region chiefs will be able to use the new system to access and review data on course sites and instructor histories.

A change has been made to the surgical skills lab for the eighth edition; it has been approved as an optional lecture/skill combination. The shock and surgical skills stations have been divided into two, to have a scenario-bases teaching of surgical airways, chest tubes, periocardiocentesis and DPL. It was piloted in Europe, Saudi Arabia and the US with positive responses from faculty and participants.

The ATLS International Meeting was held over the weekend, with representation from more than 25 countries. The first courses in Pakistan will take place later this month. India has been approved to hold courses, and a site visit will be made in November. Today the committee also received applications from Slovenia and Nigeria. China has expressed interest again, and this time the committee will work directly with the mainland and try to incorporate the program in Hong Kong to create one large program.

The ATLS international Meritorious Service award was this year awarded to Michael Hollands of Sydney.

Regional Committees, Dr. Knudson

Dr. Knudson acknowledged and thanked the region chiefs for their hard work. Work is now concentrated on the 2008 Residents Trauma Papers Competition, with presenters to be chosen in early January.

For the first time, a resident winner’s paper has been fast-tracked into JACS. Dr. Knudson worked on the paper with the author, Dr. Alexander Ereso, and Dr. Eberlein accepted the paper without further editing. She feels this should be a great incentive to residents to participate in the competition. The winning clinical and basic science papers will both be eligible for publication in JACS.

At the 2008 Annual Meeting in Washington, DC, some regional activities will be highlighted at the Special Session, which may be of interest to members of Congress.

The COT will host the first annual resident’s case presentation luncheon, to encourage active participation in the COT activities.

The annual reporting form is in the process of being revised. The regional committees hope to have their own SharePoint site where information can be assembled. The ACS staff will populate whatever information fields possible before sending out to the chairs.

The Meritorious Service Award, selected by the region chiefs on a confidential basis, will be announced at tonight’s banquet.

Report of the Ad Hoc Committees

Membership, Dr. Luchette

The committee met yesterday and at the AAST meeting to come up with some nominations to put before the Board of Regents for approval later this week. A proposal for eleven new members will be moved forward, including two burn surgeons and re-establishment of a representative for urology. This will take the membership of the COT from 69, four years ago, to 76. Any recommendations should be emailed to either Dr. Luchette or Carol Williams Carol Williams.

A lot of inquiries are made about how someone gets on the COT. The best process is to get active at the state level. That could lead to up to 20 years of activity with the COT.

Verification/Consultation, Dr. Mitchell

The VRC will be meeting today from 12:00 - 5:00 pm, and tomorrow will have the annual reviewers meeting, an open meeting to update all hospitals on the VRC program and a meeting with the trauma program managers.

Dr. Mitchell thanked the committee members, who make about 140 -150 site visits a year. So far they’ve made 106 and expect to finish the year with 148, based on what’s scheduled. Turnaround time for reports is about a month from the visit. Last week the website showed about 250 currently verified trauma centers.

The Green Book has about 300 requirements, and a lot of those had to be integrated into the new PRQ. Last August chapters were assigned and work done to get the new requirements into the PRQ, the template and the reviewer’s questions. This was submitted to the ACS IT department and will be ready for hospitals by the beginning of 2008.

Today’s meeting will have the first follow-up on requirements for Level IV centers; more will be added to the two that have been in past books.

There has also been some discussion about a COT course related to the Green Book. This is in planning stages, and the committee is working on it with the STN. It will probably be a one day course to prepare trauma centers for a verification visit.

Dr. Mitchell hopes to create a new position, clinical liaison. This will likely be a trauma program manager or someone with similar qualifications. This person would not necessarily be located in Chicago.

To follow-up from the Denver meeting, the committee has classified deficiencies into Type I and Type II. Type I deficiencies concern requirements needed to be in place at the time of the review. It’s allowable to have up to three Type II deficiencies at the time of the visit, and centers will have one year to get those requirements accomplished in order to have verification for three years. Since May, several hospitals have fallen into this category.

The committee will be implementing an internal PI process, which will have feedback relating to the process, the office and the reviewers.

Rural Trauma, Dr. Foley

The committee will be meeting this afternoon from 12:30 to 2:30 to discuss a number of issues, including the population of the website and portal with information on rural trauma. They will also have a demonstration on SharePoint.

They are still working with the Dr. Goldman and the ACR on the transfer of x-rays from Levels III and IV centers to Levels I and II.

RTTDC has now transitioned over to ACS for administration. Work is beginning on the 3rd edition. Because of the complexity involved with sponsoring CMEs they cannot be provided by the ACS until the third edition comes out.

Over 150 courses have now been held, and the evaluations have been excellent. In West Virginia, Dr. Kappel and Dr. E. Phillips Polack have been looking into the communications between the Level III and IV centers and the Levels I and II. They have given approval to add a communications module to the course and will pre- and post-test to get information on its educational value.

Dr. Rotondo, through the Systems committee and his contacts with national organizations, has been able to get RTTDC included in the flex grant funding system. Dr. Foley will be sending out further information on this funding to all of the COT members.

Disaster and Mass Casualty, Dr. Hammond

The two major activities of the committee center around development of the DMEP (Disaster Management and Emergency Preparedness) course and their obligations under the TIIDE grant.

The DMEP course has now been given about a dozen times. The course content is finished and the syllabus being refined. They are also working on ways it can be used as a certification tool.

The course is being given as a PG session again this year. There is also a plenary session on blast injuries.

The committee has participated in rewriting the ATLS triage exercise and an appendix on disaster-specific activity.

They also contributed to the CDC bomb and blast curriculum referenced by Dr. Salomone earlier.

They have been involved in all three aspects of the TIIDE project. They are the lead agency on the translations project. The white paper will be completed later this year. They’ve been involved with NASEMP on developing a national standard for field triage, and will make a recommendation to the COT to adopt the plan being put forward.

Other projects include revamping their website to make it more interactive with a disaster Wiki to gather collective expertise. They would also like it to act as a clearinghouse for certain guidelines; hospital stockpiles, for example.

Besides working with Dr. Casey and Operations Giving Back, they are working with Dr. Jon Krohmer at the Department of Homeland Security, on potential volunteers and their skill sets.

They are moving into issues regarding hospital and system preparedness. A gap analysis has been done in New Jersey, and they will now try to move on to another area.

Also, they are working again with Dr. Salomone and the Prehospital Committee to develop an after-action template that would be more germane to the kinds of things done by surgeons.

Outcomes, Dr. Pasquale

The committee meets this afternoon and has several ongoing projects. One is the development of evidence-based definitions of outcomes. Several will be presented this afternoon, for submission to the data dictionary for use by the TQIP and other studies.

The other project is the preventability assessment that the committee currently uses. Some questions have been raised about its utility and reliability. Dr. Tinkoff and a subgroup will look at a study that found it’s difficult to see agreement or correlation amongst institutions and reviewers when looking at preventable assignment for mortality.

The committee is also working with Dr. Thomas Esposito and his AAST injury assessment and outcomes committee on validation of the organ injury scaling system, part 2. EAST has accepted their abstract on the validation of OAS 2, which gives these groups an opportunity to collaborate on a manuscript.

At their last meeting, they adopted an evidence-based definition for quality of life after discharge. The recommendation was to use SF36; and Drs. Brasel, Schermer and Kuhls have volunteered to put together a prospective evaluation of it.

Systems, Dr. Rotondo

The committee is very active, and will meet today.

Nancy Longley of Weber Shandwick has worked with them and the Wall Street Journal, as well as networking them in with Brian Williams and Nancy Snyderman on NBC Nightly News. Wednesday was an important day, with some national attention on trauma system development.

The committee had representatives at the National Conference of State Legislatures. Dr. Rotondo discussed the rural trauma and system development issue with them. They have now assisted in rewriting the flex grant funding guidance. 45 states in this country that have critical access hospitals receive about $490,000 per year in federal funding. Some of the things they are now allowed to apply for are becoming Levels III, IV and V trauma centers, for RTTDC, for benchmarking indicators and scoring assessments or BIS facilitation. Through this guidance there is also funding for a consultation from the college, which is key. They will work with anyone interested in trying to get this money accessed into their state. They also went to the flex grants management meeting, to talk to the people who actually have the money.

There is an upcoming meeting with the National Association of State EMS officials, with whom it is very important to interface. They are often the hub for trauma system development, and the COT members need to know them and be known by them.

The committee is indebted to Dr. Winchell for a paper objectifying the consultation process in retrospect. Also to Dr. Nathens, for getting the White Book, the consultation guide, into the hands of the college editors in record time.

In addition, they have been steadily working on this trauma systems overhaul, finding and training new reviewers, and changing how consultations are done. Jane Ball has rewritten the client manual which is given to states preparing for a systems visit, and the reviewer manual also.

Dr. Rotondo ended with a presentation to Gail Cooper, on the occasion of her retirement. She has been a national leader in EMS and trauma systems development, and made a major mark in injury prevention and control, as well as public health policy.

Surgical skills, Dr. Luchette

The surgical skills committee was convened about four years ago, with the purpose of continually evaluating and developing courses or tools for training in the principles of operative management for the injured patient.

Three years ago it was recognized that the audiences to address were medical students, junior and senior residents, and fellows and community surgeons. They needed to develop a matrix and fill it for knowledge, technical and exposure skills. Their efforts have been focused on senior residents and community surgeons.

After the last meeting, the Executive Committee has endorsed moving the ATOM course into the COT, which was approved by the Board of Regents earlier this week.

Since then they’ve been focusing on the Operative Exposure course, and have taken a modular approach, with five co-editors. There are various exposures not covered in the ATOM course, but in which they feel it important for surgeons to be well-versed. These are head and neck (primarily vascular injuries of the neck), thoracic, abdominal, pelvic and extremities. This course is meant to complement ATOM.

Dr. Kuhls has led the effort for medical students, and at the committee meeting tomorrow, will give an update on the evidence supporting various educational models addressing their needs.

There are tentative plans for a pilot cadaver course within the next year. They are reviewing the curriculum. They are also exploring bedside procedures for junior residents as a follow-up to the course developed by Dr. Velmahos several years ago. Finally, they are working on completion of surgical skills for the medical students.

Report of the Specialty Chairs

Neurosurgery, Dr. Valadka

Dr. Valadka believes there is frustration between neurosurgery and the trauma surgery community, stemming from the way the acute care surgery concept was developed and promulgated. Seemingly, the leaders of the trauma surgery community do not feel it is still an issue, but manuscripts and surveys are still being published which stir it up.

This is Dr. Valadka’s last meeting, and he sees the best thing to have happened is an increasing awareness in neurosurgery of COT activities.

Neurosurgery has been coming up with its own ways to deal with the issues all share in common, in terms of covering emergency departments. The AANS is finishing a document, to be submitted to their board of directors at the end of the month. It may become a type of Green Book to verify neurosurgical emergency centers, but it is hard to say how it will evolve. Dr. Adelson has also launched an initiative to figure out what works in some places, but not in others.

Dr. Valadka thinks it better for the neurosurgical leadership to work on initiatives with the COT, but that it is becoming increasingly difficult to do so. He would like to again call attention to neurosurgical concerns that have not actually been resolved and are still very much an issue in the neurosurgical community. And this is in the face of much greater issues with the whole trauma system. It would be more effective and efficient to work in concert, than for each organization to develop parallel mechanisms to resolve problems.

Dr. Fildes thanked Dr. Valadka for his honesty, and announced that he has been invited to the AANS for a discussion. The COT wants the right care for the patient in the right place and the right time, and a key requirement for that is collaborative practice. Dr. Fildes feels that no differences have been raised, which cannot be settled.

He also remarked that he is commonly questioned about the acute care issues, and that the COT is not part of the curriculum planning. It’s an AAST program, although so many COT members belong to both organizations it is sometimes hard to distinguish where one stops.

He added that Dr. Russell is promulgating the concept of a unified ‘house of surgery’, and that his line of thinking coincides with Dr. Russell’s.

Dr. Teague, Orthopedic Surgery

The OTA annual meeting is next week in Boston. A couple of COT members are preparing for that. Dr. Tornetta is the local host. Dr. Anglen is the OTA president this year.

A letter was sent to several orthopedic surgeons with dual membership in the OTA and ACS, requesting their interest and commitment regarding membership on the COT. They received several affirmative responses and have forwarded those names to the Membership Committee.

He feels the Orthopedic Board group wants to help with the work of the COT, but may not yet know how to do that effectively. He asks the leadership to help figure out their place in the workings of the COT. They have tried to make sure they are represented on all the committees, but would appreciate some direction on greater involvement.

With regard to community call involvement, the OTA leaders just met with the AAOS to further evaluate that issue. The OTA continues to advocate for continued improvement in community call involvement from non-trauma orthopedists.

The number of orthopedic residents going into trauma fellowship has gone from less than 20, four or five years ago, up to 80-90 applicants this year.

Dr. Cooper, Pediatric Surgery

Dr. Cooper began with a call for all to attend SBI training. He participated in one at the AAST meeting and recommends it as outstanding training. He’s implementing it in his trauma center right now.

The main projects being focused on this year are;

• Working with TQIP to identify specific indicators to be included in the TQIP package
• Working with Dr. Jurkovich’s group on Acute Care Surgery
• Working with Dr. Clark on the National Sample Project to identify funding and include the pediatric stratum in the sample being developed by his committee
• Continuing to support the work of ATLS; a review is underway by the international committee and they hope to have input

Dr. Salomone has asked them to identify issues in PHTLS. They will also work with his committee on finalizing the termination and resuscitation paper.

They are working with the Disaster Committee to improve the DMEP course materials.

Dr. Mooney is the representative on the VRC, and they continue to advise on matters of interpretation that arise in pediatric site visits.

Dr. Cooper thanked Dr. Nathens for the opportunity to work on the revised Gray Book, and the NTDB staff for their work on the combined adult/pediatric NTDB report.

Legislative Report, Adrienne Roberts

The big legislative issues are Medicare payment reductions. A 10% cut is scheduled for January 2008, but they are working very hard to make sure it doesn’t happen.

The fix for 2008 will cost 34 billion over 10 years. They are still working to replace the SGR, but Congress keeps putting this off and it keeps getting more expensive each year.

They are also still doing all of the quality measurement and value-based purchasing involved in P4P. The trauma re-authorization bill introduced in the Senate and House funds the program through fiscal year 2012, with 12 million for 2008, 10 million in 2009, and 8 million for the remaining three years. It was passed by the Senate Health Committee, and the House, and President Bush signed it into law on May 3rd.

They have been working with the PR firm on some recent media exposure, which may help other efforts to get funding.

On payment issues, she would like to let everyone know what was included in the CHAMP bill. This was the SCHIP bill passed by the house; there was another bill passed by the Senate. The House bill included a .05 increase for 2008, divided into six separate conversion factors. This was based on a proposal developed by the ACS and the AAOS. This is an answer to replacing the SGR; for years no one on the Hill has had an answer, so we developed a proposal we thought would work. It was included on the House side, not on the Senate side; when they conferenced the two bills they had to dump all the Medicare provisions and passed a straight SCHIP bill, which the president then vetoed. Congress is now working on another Medicare package that will include either a one- or two-year fix.

Some of the EMS regionalization bills that were introduced by Senator Barack Obama and Representative Henry Waxman were based on the IOM report from last year. It would create four demonstration projects to develop regional systems of emergency care based on the trauma system model. It provides a placeholder, something to point at and from which to continue work. The ACS is supporting these bills.

The legislation introduced by Mary Bono of California is designed to provide physicians with a tax deduction for EMTALA mandated services provided to the uninsured.

The new building will be ready by 2010, for the Clinical Congress in DC.

March is the key time for appropriations, and a good time for the planned visits from the COT members during the 2008 Annual Meeting

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Dr. Fildes adjourned the meeting at 12:30.