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Mon Dec 31 13:59:43 GMT 2007

Regarding "standards of EMS and trauma center care": Justice Louis Brandeis put it best in commenting on the behavior of public officials -  "Sunshine is the best disinfectant." Unless all the trauma centers in a system or a region meet regularly and perform true open, honest, and non-punitive peer review of all cases treated, there will be little opportunity to reduce variability and improve outcomes by changing trauma surgeons' behavior. Many systems and regions have a Trauma Audit Committee (TAC). In San Diego we have a Medical Audit Committee (MAC) and a Prehospital Audit Committee (PAC). I've visited other systems and attended their TACs only to find cultures of defensiveness, opinion based conclusions, or, unfortunately, blaming poor outcomes on the patient. Our MAC is going on 24 years of monthly meetings with over a 90% attendance record by all 6 trauma center medical directors and the County EMS. Each month, the PAC also reports on a multidisciplinary review of all pre-hospital quality issues. We've learned a variety of things that are worth considering. Here are my top three for trauma surgeons; 

First and foremost: A surgeon has to have peers of equal qualifications to answer to and the more experience you have the more important it is to feel the need to do things in a manner that will make sense to your colleagues. Left alone, we become stale faster than yesterday's bread. 

Second: Abandon your assumptions at the door. If you can't defend what you are doing with valid literature, you need to really worry about the legitimacy of your "practice habits". At least try to have "practice recommendations" that others agree on for everything you do that are based on either proven or promising literature. 

Third: Create a culture of confession. It starts with the trauma director being brutally honest and critical of his or her own behavior and outcomes and supportively and constructively critical of colleagues. You'll know you've accomplished this when a colleague tells you as soon as possible of a mistake in terms like "let me you tell you how my thinking went wrong..." and you all are talking in terms of errors in judgment or technique or delays in diagnosis. It can't happen unless the boss leads the way. 

This is an inherently dangerous game we play. Unless we take the professional athlete's approach of constantly measuring our performance and trying to understand errors to avoid them the next time, we guarantee poor outcomes.

Mike Sise

San Diego

________________________________

From: KMATTOX at aol.com [mailto:KMATTOX at aol.com]
Sent: Sun 12/30/2007 6:37 PM
To: trauma-list at trauma.org
Subject: "Standards" of EMS and Trauma Center Care

I would agree with Dr. Ursic, that ideally, EMS, Trauma, CriticaL Care, and 
Acute Care Surgery would be "standardized."   However, among the  trauma
centers in Houston (There are only two level I, and 8 Level II), there is  not
agreement as to even standards of care regarding fluid management,  hypothermia,
and continuity of care for simple hand and wrist  fractures.     

One major problem is that each "trauma surgeon" believes that her/his 
particular approach should be the standard for their community.    Indeed, as our
government and HHS is now discovering, there are often more than  one, two,
three, or even 10 acceptable and standard approaches to one particular  clinical
problem.   The differences are  judgement.     

We are discovering that the "BEST PRACTICES" developed by hospital 
non-physicians are often punitive and regulatory for control  purposes.    

Soooooooooooooo

How do we reach agreement as to what would be the standard. ??

k

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"Standards" of EMS and Trauma Center Care