Trauma Services AMN Healthcare RCS

The Trauma Service; can it be the hospital barometer of quality of care?

– Rob Clements, ASN, CSTR

– Susan Schmunk, CAISS, CSTR

ACS Expectation:

  • In Level I, II and III trauma centers, there must be a multidisciplinary trauma peer review committee chaired by the trauma medical director (CD 5-25) and representatives from general surgery (CD 6-8), and liaisons from orthopedic surgery (CD 9-16), emergency medicine (CD 7-11), ICU (CD 11-62), and anesthesia (CD 11-13); for Level I and II trauma centers, representatives from neurosurgery (CD 8-13) and radiology (CD 11-39) are required.
  • The purpose of the committee is to improve trauma care by reviewing selected deaths, complications, and sentinel events with objective identification of issues and appropriate responses. The representatives must attend at least 50% of these multidisciplinary peer review committee meetings (CD 6-8).
  • Although this meeting usually is held monthly, the frequency is to be determined by the trauma medical director based on the needs of the performance improvement and patient safety program.
  • General surgery attendance at the multidisciplinary peer review committee is essential. The general surgeon is the foundation of care in the trauma program. All general surgeons on the trauma call panel should attend multidisciplinary peer review meetings. At a minimum, the surgeons must each attend at least 50% of these meetings (CD 6-8). Evidence for appropriate participation and acceptable attendance must be


The Hospital trauma service can be viewed along two separate lines:


The first line is a clinical path including physicians, nursing, therapy services, social work, and case management.  The clinical care provided by trauma surgeons, both in injury evaluation, surgical correction and critical care (ICU) is the barrier between morbidity, mortality and returning to the normal activities of daily living (ADL).  As care provided to injured patients encompasses every aspect of a medical center, there are no hospital provided services that trauma patients don’t use and benefit from.   Improved outcomes of injured patients treated at verified trauma centers have been proven through 30 plus years of data review.  The current TQIP model of developing practice management guidelines from recent outcomes data is taking improved care even further.


The second path is The Performance Improvement (PI) functions.  These functions consist of the Trauma Peer Review (for provider review) and a systems committee (titles vary and include TOPIC, PIPS, etc.) This second function is staffed by a group of specialists trained in PI relating to Trauma.  This group, generally referred to as the Trauma service staff, consists of a Trauma program manager, Trauma PI coordinator and Trauma registrar and is led by the clinical based Trauma Medical Director who must be actively caring for patients within the trauma service.  This PI function should be coordinated with the hospital wide QI department and should have the same authority, responsibility and respect as the hospital wide QI program.  Operationally, the Trauma Peer Review should have straight line accountability to the Hospital Medical Executive Committee. 


In the U.S., traumatic injuries are a prevalent cause of death, and the leading cause of death in individuals younger than 45 years. Because of the morbidity and mortality rates, The American College of Surgeons Committee on Trauma (ACSCOT) has developed a collection of quality indicators.  These quality indicators or audit filters are used to flag patient cases as trauma registrars’ abstract cases.  The identified audit filters are then vetted by the RN trauma performance coordinator for accuracy before being discussed and addressed as less than optimal care.


In the article “Are Trauma Care Quality Indicators Linked to Clinical Outcomes?” Laurent G. Glance, M.D., explained “Seven of the ACSCOT quality indicators were associated with either increased (1) in-hospital mortality or (2) death or major complications.”  This best evidenced review of quality of care provides the trauma service and the hospital with insight into processes and resources that influence patient outcomes.


Some of the quality indicators showed a strong correlation with clinical care outcomes. The researchers say:

“For example, trauma patients with an admission GCS [Glasgow Coma Scale] score less than 12 who did not receive a head CT [computed tomography] scan had a four-fold increased risk of mortality and nearly three-fold higher risk of death or major complications. Similarly, patients admitted with a gunshot wound to the abdomen that were managed non-operatively experienced five-fold higher odds of mortality compared with those undergoing surgery.”


One of the overlooked and underutilized benefits of the Trauma Performance Improvement function on a hospital wide quality perspective is the capability of viewing a smaller more condensed version of the patient population.  As the Trauma patient population intersects with every entity within a medical facility, the analysis of the quality of care can be a very accurate barometer of the quality of patient care provided within the hospital.  This review of quality within the traumatically injured patient population is proactive instead of the norm of a reactive process.  The previously mentioned audit filters are actively reviewed for each patient meeting trauma inclusion criteria, thereby identifying areas where process changes can have the greatest impact on patient outcomes.  The findings of systemic performance improvement should be presented to hospital quality for inclusion in the improvement projects and benchmarked or monitored for continued improvement in standards of care.


Share the system findings with members of the administrative suite at every opportunity, to the point that they will reach out to you to validate hospital wide responses.

Blog #1 –

Basic Steps to Make Process Improvement and Patient Safety (PIPS) Function

Blog #2 –

Coordinating Trauma Performance Improvement (PI) and Hospital-wide Quality Assurance (QA) Departments

Blog #3 –

How To Transition Individual Performance Improvement to Systemic Performance Improvement.



Society of Trauma Nurses. (2014). Trauma Outcomes & Performance Improvement Course. Lexington, KY.


Trauma Performance Improvement Reference Manual, Performance Improvement Subcommittee of the American College of Surgeons Committee on Trauma


“Are Trauma Care Quality Indicators Linked to Clinical Outcomes?” Laurent G. Glance, M.D.,