The Coronavirus pandemic has had wide-reaching effects on healthcare and hospitals. Anyone who works in a trauma center is painfully aware of the number of their personnel who have had to change roles, reduce their work time, or who have suffered a furlough or layoff.
Let’s take some time to consider a few key questions, and let me provide some suggestions and solutions.
- How might your clinical capabilities change?
- What could happen to the trauma administrative infrastructure, like trauma program manager, registry, injury prevention, and outreach?
- And how will this impact a center during its next site visit from the American College of Surgeons or other designating agency?
Inpatient Trauma Care
Even though the COVID-19 pandemic is fully upon us, a trauma center must still be a trauma center. It has to be ready to receive the next trauma patient exactly as it did before. Your clinical capabilities should not change much unless you are at a smaller Level III or Level IV center. The nurses, doctors, and advanced practice providers (APPs) will still be there, although their numbers may be reduced somewhat. Admitted trauma patients may be housed is areas different than are usual due to retasking of beds and units for COVID patients. Thus, clinical care capabilities should be largely unchanged.
But what about the administrative infrastructure? The linchpin of trauma care, the performance improvement program (PI), must continue. Without this, patient harms can and will occur. And there will be many, many more opportunities for harm due to the major operational changes occurring in the ED and other patient care units within the hospital. PI monitoring must continue!
What happens, though, when key trauma administrative personnel are reassigned or furloughed? Unfortunately, the remaining professionals must pick up the slack. The trauma medical director (TMD) will have to be more hands-on. The same goes for the trauma program manager (TPM). Any APPs or trauma nurses will also need to step up their PI surveillance game.
Trauma Program Manager
Unfortunately, some Level III and Level IV programs have seen their TPMs reassigned to other duties. These nurses typically devote only a fraction of an FTE to trauma, and any further reduction may totally shut down their trauma program activities. This is a worst-case scenario, and will likely violate the standards of your state trauma system.
Here’s what you can do if the trauma program manager is having their trauma FTE reduced or reassigned to other duties:
- Contact your state trauma system liaison and discuss the situation. Find out what the options are and how this might impact your center’s designation status.
- Meet with your administrator and emphasize the importance of maintaining high quality care for trauma patients. Try to negotiate to achieve either no reduction in your time, or minimize the reduction as much as possible.
- Throw your TMD under the bus. Point out that they will likely be devoting more time to COVID responsibilities and less to trauma. This makes your trauma FTE even more valuable and worthy of being preserved.
- Make sure your hours are fully reinstated once the crisis subsides. You will need to rapidly move back to normal operations as you start thinking about your next site visit.
The trauma registry is one of the key tools used by the trauma PI program. Unfortunately, trauma registrars seem to be considered low hanging fruit by hospital administrators when considering furloughs.
Here’s what to do if your registry personnel are being reduced or eliminated:
- You can’t really eliminate all of your registrars. This is a firm requirement in all state trauma systems. However, if you are at a smaller center, the TPM frequently assists with registry data entry. He or she may have to temporarily pinch hit for any registrar reduction.
- Some registry FTEs can probably be reduced (temporarily). The vast majority of centers have just the right number of registrars, or are possibly slightly under-staffed. A reduction will slowly increase the registry backlog and will eventually begin to impact the percentage of charts completed within 60 days.
- Temporarily eliminate registrar accuracy checking. All centers check accuracy of registry entry through some means of reliability testing. This can be stopped for a period of time, although it is only a short-term patch. It must be restarted at some point, and each center will need to decide how aggressive they will be in rechecking old data.
- Temporarily curtail or cease reporting activities. Do your registrars have to enter data for your state? Do they have to generate reports for your hospital administration or your hospital system? Stop! They are as busy and as strapped for people as you are, and will not be paying attention to any new reports. But do plan on catching up as quickly as you can once you are up to your usual staffing level.
- Rapidly ramp up to your normal registry contingent once the crisis is over. You will need all hands on deck to clear out the back log.
Unfortunately, your injury prevention team are probably the most expendable people in your trauma program. Much of what they do involves close contact with groups of people, which is just not possible at this time. Although there is always a role for injury prevention, its delivery is just not practical at the moment.
Here’s what to do if your injury prevention (IP) personnel are being reduced or eliminated:
- Not much, I’m sorry to say. Your IP personnel may not be clinically trained, and probably can’t support other parts of your trauma program. You will need to get very creative to find them a spot within your paid program staff.
Unfortunately, dedicated trauma outreach personnel are perceived as even lower hanging fruit than registrars. Outreach staff may be desk-based, mobile, or a combination of the two, Desk-based outreach includes writing and sending followup letters and making followup phone calls. Mobile outreach is conducted in person, and may be performed by the TMD, TPM, or dedicated personnel.
Overall, this activity has a lower priority in your trauma program right now. It is very important in the long run for education, marketing, and professional satisfaction for those who send you patients. But for now, it can be temporarily cut back or eliminated.
What can you do if your outreach personnel are being reduced or eliminated?
- Use other personnel to substitute for your outreach people. Trauma nurses or even the TPM may help out, but this has a lower priority than their other duties. And it should only involve in-house duties like phone calls and emails.
- Bring them back as soon as the crisis subsides. Outreach is vital to the long-term survival or your center.
Your Next Site Visit
Well, you’ve somehow survived all the contortions of the Coronavirus pandemic. You will have your next reverification or redesignation visit at some point, sooner or later. If it turns out to be sooner, the pandemic will undoubtedly throw a few monkey wrenches into your numbers. Here are some examples:
- Trauma registry admissions (for Level I centers)
- Multidisciplinary trauma PI committee attendance
- ATLS and other educational course completion
- Registry concurrency
- And a few other unexpected surprises!
The American College of Surgeons Committee on Trauma (ACS-COT) has signaled that they are aware that the COVID crisis may create some difficulties and irregularities during the verification process. They have stated that “provisional allowances” can and will be made on an individual trauma center basis. But the devil is in the details and these have not been clarified yet.
So what should you do?
- Start working on your ACS pre-review questionnaire (PRQ) very early. If you are state-designated, begin filling out your state application.
- Determine which data elements are going to be problematic.
- Document, document, document! Collect every piece of information you possibly can supporting and justifying the events that led to every irregularity.
- Notify the ACS-COT of any potential issues as early as possible. Contact the office at firstname.lastname@example.org and provide all of your detailed information so they can make a determination and help you.
Remember, your site reviewers are experiencing the same issues you are. The ACS-COT will be seeing an onslaught of applications with the same problems you are experiencing. You are not alone! Just do what you have to do to get through this while guaranteeing the highest quality care for your trauma patients.