For the past year, trauma center designation and verifications visits have been essentially shut down. But now, many states, as well as the American College of Surgeons Committee on Trauma, have started to resume these visits. The spectre of COVID-19 is still around, so most agencies have adopted some sort of virtual site visit.
Most trauma centers have a lot of history and experience with on-site verification and designation visits. It should come as no surprise that many are nervous about their first virtual visit. The processes are different. There is technology involved that may be glitchy. So it creates a great deal of anxiety at the hospital hosting the visit.
This article is the first in a series of what I call “best practices” for centers hosting a virtual site visit. Remember, these are my ideas and my opinions alone. The verifying and designating agencies have not yet published their own guidelines. What I publish here is meant to guide you until more global guidelines from the agencies responsible for your site visit are available.
So let’s get started with the part of your site visit with the most moving parts, the virtual walkthrough. Nearly all agencies schedule some time to tour the physical plant of your trauma center. They do this to verify that the required equipment is available, processes are in place for safe transport of the trauma patient to various care areas, and to have an opportunity to talk with the clinicians in those areas. Unfortunately, this is the most difficult part of a review to convert into a virtual experience.
I’ve divided these best practices into three major categories: the equipment, the people, and the plan. I’ll address each in the following sections. I will also provide my recommendations, as well as the rationale for them.
Preferred device: a tablet or mobile phone camera on a mount. The best camera for the walkthrough is the one on any tablet or smart phone. These cameras are easily portable and pointable. The camera operator can see exactly what is in the frame of the camera. Compare this to the classic “workstation on wheels.” These are clunky, difficult to navigate, and impossible to see what’s on camera without standing right in front of it.
In my opinion, the best option is a tablet camera. These are a bit larger than a phone, so the mount is more important. I prefer a rolling platform, like the ones attached to those tablet-based interpreters that many hospitals use. The tablet clamps into place and the platform can be rolled and spun around easily, and the video action is very smooth.
A smart phone camera is another good option. It should be mounted on a selfie-stick that is fully retracted (short). This allows the operator to move and point the camera with one hand. This option is more flexible than the tablet, but is a bit more sensitive to caffeine levels in the camera operator.
The camera should be signed into your teleconferencing software (Zoom, Teams, Webex, etc) in advance of the walkthrough, with audio and video off and the operator monitoring the site visitors’ progress. When a particular area is ready for the reviewers to visit, turn both back on.
Preferred number of devices: minimum of 2. Typically, six or more areas may be visited during the walkthrough. It is far easier to station a camera in each area ready to go live once the visit of the previous area is finished. This can be accomplished with just two cameras if you are clever. As soon as one camera is finished and the next area goes live, the operator hightails it to the area following it on the visit list. However, it’s probably just easier to have a camera on a stick stationed in each area to be visited.
Preferred camera orientation: landscape (horizontal). This allows a wide area to be visible at all times during the walkthrough. And be sure to turn the rotation lock on so the orientation doesn’t change if the camera wobbles a bit.
Microphone / speaker. Make sure that the camera / phone speaker can be easily heard in the various areas of the walkthrough. Be very aware of ambient noise levels. You might consider using an inexpensive bluetooth speaker with built-in microphone. Pair this with the phone and pass around to the people being interviewed so everyone can hear and be heard. But make sure it has high quality! Stay away from simple lapel microphones; they just don’t sound so good unless they are very close to the speaker’s mouth. Be sure to obey COVID precautions, though!
Wifi / cellular infrastructure. Hospitals are notorious for having dead spots in strategic places. Make sure to test the signal strength in every area that will be visited. If signal strength for one network (wifi or cellular) is weak in one zone, use the other network.
Backups. Remember, everything that possibly can go wrong, will. The particular device you are using may crash. It may run out of power (lame). It may just start acting flaky. Always have another device signed in at each location and ready to switch audio and video on in case the primary camera starts acting up.
Now that we’ve got the hardware down, let’s talk about the people.
The camera operator. The operator should be facile with the teleconferencing software so they can connect to the camera, troubleshoot, and go live when needed. They should not, however, be part of the hospital team. The camera operator stays behind the camera at all times and cannot be interviewed. This means they can’t be your trauma program manager or trauma medical director. These two will be on-camera, answering questions. And the operator needs to take care to keep the camera stable and focused on the people talking.
TMD and TPM. They are the stars of the show. One of them should be stationed in each area to answer questions and direct the microphone to people the reviewers want to speak with. Once an area shuts down, the TMD or TPM can then hopscotch to another area before it goes live. You can also put your assistant/associate TMD (if you have one) and your trauma surgeons to work by stationing them in areas such as the ICU or OR.
The traffic cop. This is an essential role in each area. Their job is to keep traffic away from the vicinity of the walkthrough. They should also direct patients away from the camera, the camera away from any patients, and keep noise levels down near the camera.
Masks. Yes, COVID is still with us for the foreseeable future. Everyone will need to wear masks. But be sure to use paper masks. Cloth masks cause more muffled speech which can be harder to understand.
As you can see, the video walkthrough is a complicated dance routine. It takes a lot of planning to pull it off flawlessly. Let’s walk through the steps.
Settle on your hardware and software. Obtain the devices listed above and make sure your teleconferencing software is installed and functional.
Plan your route. Areas typically visited are: the emergency department, starting in the ambulance bay and moving to your trauma bays; radiology / CT scan; OR charge desk, PACU desk; surgical ICU; blood bank. If your helipad is remote, you may need a camera there to show the reviewers how the patient moves from there to the emergency department. Note: beginning in May 2020, the American College of Surgeons no longer requires a stop in radiology due to frequent connectivity issues. The radiology liaison, director, or a technologist should be available in the ED portion of the walkthrough to answer questions.
Plan your personnel. Figure out who will be the “host” in each area. Will it be the TMD? The TPM? Someone else? This is important because you will need to determine the next area they proceed to when their location is finished. This will also help determine the order that the cameras will go live.
Test, test, test! Rehearse the entire process until it goes smoothly. Set up your teleconferencing software on a desktop system at a central location. Then deploy all of your cameras and personnel to their respective areas. Turn on the audio and video for each one in sequence, just like you would during a real walkthrough. This allows you to check the audio and video quality and plan how the camera operator will need to move around in each area. The people at the desktop can judge the quality and signal strength at each location and make adjustments to achieve the best possible.
The Final Result
If you have faithfully followed the advice above, your virtual walkthrough should go very smoothly. Just remember, though, it’s much easier to work with people than with technology. Be prepared for surprises and use your flexibility and creativity to overcome them. And of course, always check with your verifying or designating agency to see if they have provided any additional instructions or guidelines for the walkthrough. Their preferences will always supersede these. Good luck!