2013 OTA President's Message: Standardization and Systems: Steps We Must Take Together
Dear Members and distinguished guests. It is my honor and privilege to have the opportunity to address all of you as OTA president, but before I get to the substance of my talk I would be remiss if I didn’t share with you my perspective about the state of the OTA, and highlight some of the significant accomplishments of the past year. When you join the OTA Board, it is immediately obvious how competent our staff in Rosemont are, and how passionate and energetic our members, all of you, are. The OTA is in a great position thanks to the leaders who have come before me, and just over a year ago our Board made changes to our organizational structure that are already paying off. I am referring to the organization of our committees into four Councils: Education, Research, Membership Services, and Governance. This was done to facilitate interaction between our committees and our Board. Each committee has been given a specific set of goals, as well as metrics to use to assess their progress towards meeting those goals. Each summer during our annual strategic planning meeting, new goals and charges are created as prior tasks are completed. The accomplishments that our committees have achieved in just this past year demonstrate that we that these changes are already paying dividends.
As an example of how well this process has worked, I’d like to highlight our new Evidence-Based Quality, Value, and Safety Committee, capably chaired by Bill Obremskey. One of this committee’s charges was to evaluate practice patterns of OTA members in controversial clinical areas. Surveys like this accomplish two things. First, the information can be used to improve patient care by highlighting areas where our individual practices might vary from current evidence-based concepts. Conversely, where there are gaps in the literature and lack of evidence-based guidelines, the practice patterns of experts might reasonably be considered to be the basis to establish a benchmark standard for clinical practice going forward. In its first year, this group has already completed studies that document practice variation among OTA members with regard to DVT prophylaxis and the management of open fractures. You’ll hear more about this later. What excites me is that this sort of data will not only benefit our members and patients, but will in-turn provide our Research Committee with important information regarding future research needs, guide our Education Committee as they improve our educational offerings, and even highlight areas where our Healthy Policy Committee might be put to good work. We are now able to profit by the inter-relationships of our various committees. Projects like this will fuel our organization for years to come, and ultimately benefit our patients.
Another new group that was recently formalized into subcommittee status are the OTA members of American College of Surgeons Committee on Trauma, which oversees many of the national quality measuring and reporting initiatives such as the National Trauma Databank, and the Trauma Quality Improvement Project or TQIP. This will cement what we hope to be a fruitful relationship between the ACS and the OTA.
Of course, perhaps the most visible aspect of the OTA is this meeting. Our program Committee, led by Tom Higgins and Bob O'Toole, continues to innovate and has created one of the best orthopedic congresses in the world. Everyone who worked on the program committee deserves our thanks; without their hard work this meeting could not take place. In addition, our Education Committee chaired by Bill Ricci, Health Policy Committee under Michael Suk, Research Committee led by Todd McKinley, Classification and Outcomes Committee chaired by Craig Roberts, and the International Committee under the guidance of Bill DeLong represent other examples of truly hard-working committees that continue to push this organization forward. Finally, many of you have volunteered to serve on new project teams. One is looking at how our On-Line offerings might benefit from use of social media platforms as well as new forms of digital media and online education, another is looking at identifying databases that all of us may use not only for research but also to improve our individual practices, and yet another is beginning to plan upcoming 30th anniversary celebration next year.
In addition to these groups I have mentioned, we have many other committees that serve the OTA and whose work benefits our members and our patients. I apologize for not having the time to go over each and every one of our committees and all of their efforts now. You’ll be able to hear reports from many of our committees in the business meeting that follows this talk. In addition, please watch for (and read) the OTA newsletter, FractureLines, which will keep you updated on all of these activities.
I have just described how complex the OTA has become, yet despite this complexity we are thriving and remain an efficient, successful, and high-performing organization. However, another common outcome of increasing complexity is chaos. Our organization has avoided this, but it seems that chaos is more and more an apt descriptor of the health care settings in which we work. A scientific field that I have long been interested in is so-called chaos theory, or the behavior of complex systems. There are many aspects of these concepts that have very meaningful application to the practice of orthopedic surgery. I’d like to use the rest of my time to discuss the issue of complexity as it applies to the delivery of trauma care, and to highlight things that each of us can and should do to reduce chaos and restore efficiency and predictability to our practices.
Briefly, chaos theory is a branch of mathematics that describes the behavior of so-called dynamical systems. These are deterministic systems that yield widely varying outcomes. Even though the model can be described by an equation, long-term prediction is impossible. Many consider the weather as a great example of this concept. However, clinicians will immediately think of the parallels with the practice of surgery. How many of you can predict the final outcome of a given injury, or be able to exactly predict the results when recommending a certain procedure to a patient? How variable is the care that we provide in our hospital from day to day or from provider to provider? What governs the care provided to patients or the outcomes that we achieve? Is it a predictable equation or an unpredictable one? What can we do to make outcomes less chaotic and therefore more predictable for our patients? These are critical questions in health care.
In addition to the inability to predict long-term outcomes, another aspect of complexity theory is something known as scalability. Fractal geometry is an interesting and very visual example of this; fractals are patterns that are similar whether viewed at the microscopic or macroscopic level, or anything in between. Although not exactly the same, our trauma systems exist at the micro and macroscopic levels and must be viewed from many perspectives to fully appreciate what is there; possible viewpoints are those of the individual surgeon, a practice, a hospital, a system of hospitals, or a large region or even nation. When we do so, we see that the problems and potential solutions to those problems at each level are remarkably similar.
Beginning at the level of a single surgeon, all of us are faced with increasing complexity simply based on the explosion of medical knowledge. How does one keep up with advances in knowledge and learn new techniques? In engineer-speak, how does one separate the signal from the noise, and from among the reams of available data find pertinent information that applies to one specific patient? As I have alluded to, lack of data (or familiarity with available data) leads to practice variation and unpredictability, and this is chaos by definition. As an example, I’ll refer again to our EBQVS committee’s survey that documented surprising practice variations among OTA members regarding DVT prophylaxis.1 This practice variation is not unique to thromboprophylaxis, or even orthopedics. It is a ubiquitous problem in medical care in general. As you are all aware, there is a spotlight on health care now, with policymaker’s being very concerned about concepts of cost, quality, and value. Big Data is everywhere, and soon (if not already) we will find our individual data available on the internet, and we will be compared to each other.2 How does this variation that we know exists come about, and how does it look to “outsiders”.
We need to make our practices more uniform, more standard, in order to achieve predictable outcomes. One way to achieve this is with the use of simple checklists or protocols. Atul Gawande, a neurosurgeon, author, and expert on surgical safety, presents a compelling case for the routine use of checklists in medicine in his book “The Checklist Manifesto”.3 In this book, Gawande states that “Medicine has become the art of managing extreme complexity and a test of whether such complexity can, in fact, be humanly mastered.” 4 Checklists help in simple procedures, like the pre-operative timeouts that all of us now use in the operating room, but they really shine in more complex situations. Routine use of checklists in medical practice has resulted in dramatically reduced complications in our intensive care units and emergency rooms.5,6 The introduction of the World Health Organization surgical checklist reduced complications by one-third in the hospitals studied in the US, UK, Canada, and New Zealand, all developed countries with sophisticated health care systems already in place.7 Checklists change the equation that determines outcome from one that is unpredictable to one where the outcome is known.
At the hospital level, complexity is increased by the increasing number and types of providers involved in patient care. Trauma patients have different medical teams caring for their constellation of injuries, and among each team there are constellations of different types of providers. Advanced-practice providers have become ubiquitous. Resident duty-hour limits effectively increase the number of residents involved in a patient’s care and require more hand-offs. Conceptually, doesn’t this look like the fractals I showed you earlier? Whether you look closely at one service with lots of specific providers, or you look at the larger picture of several different services trying to coordinate their care, the picture and the problems are remarkably similar. The lack of meaningful communication among these providers introduces complexity and the potential for errors and therefore compromised outcomes. The term “interdisciplinary” now has several levels of meaning. On the macroscopic scale, it refers to the sharing of information between subspecialists, like orthopedists, neurosurgeons, and trauma surgeons who all are caring for the same patient. Such communication is vitally important and rarely formalized in our trauma center. As Dr. Gawande notes in his book, communication becomes ever more important as the overall complexity of the situation increases. How often do you see mistakes whose root cause is poor inter-service communication? How often do patients and their families complain about obviously poor communication and planning among different services and ask why the right hand doesn’t know what the left hand is doing? How many of you have had a complication because some provider on the trauma service discharged a patient that you operated on with inappropriate activity orders, or wound care management, or simply just follow-up. Checklists are not meant to box-in the surgeon or to manage what the surgeon does; they are ways to let the surgeon be a surgeon and be confident that the more mundane but just as important aspects of patient-care are done correctly as well.
An example of this sort of multidisciplinary communication is the timeout that I bet all of us use in the operating room. Many of us complain about whether these actually prevent surgical complications, despite the published data that they do, but how many of us have adopted such methods into our clinics and ward care where the impact may be much greater? One of the great values of these rituals is that it formalizes the development of the team mentality, where those around you are more likely to become invested in your patient and help you care for them. Ten years ago, Dutton et al., reporting in the Journal of Trauma, found that multi-disciplinary rounds reduced length of stay by 15%.8 It is surprising that multidisciplinary care rounds have not become a more standard practice. Earlier this year, the new fellows at Vanderbilt decided to avoid these problems which they all witnessed as residents in their former institutions, and instituted a daily 7 am “trauma rounds” to ensure this sort of communication, and found it so beneficial that they wrote an editorial about their experience.9 Checklists and protocols that ensure that meaningful communication among different providers occurs are just as important as procedural checklists. None of us can remember everything, and modern medical care is meant to take advantage of something called “collective intelligence”. This concept is so important that MIT has a whole center devoted to the study of this phenomenon. By ensuring that information and responsibility is shared among a team, processes become standard work, mistakes become less and less common, and the team becomes efficient. All of us can do this by creating teams that communicate and function as an integrated whole. The surgeon can be a surgeon and not worry about whether someone’s foot pumps are kept on.
A great example of how such standardization and protocol-driven care improve health care delivery in orthopedics are the geriatric hip fracture programs. Over 300,000 hip fractures occur in the United States each year, with a mortality rate that remains around 20%; while many more surviving patients lose their independence. The management of these patients is complex and often requires multiple specialists. Standardized hip fracture co-management protocols, such as those developed by Dr. Stephen Kates and colleagues in Rochester, and presented at this meeting in the past, have demonstrated dramatic reduction in complications rates, improved outcomes, and decreased costs.10 Reduced to their fundamentals, programs such as this are checklists that define care responsibilities and protocols, ensure that procedures are performed in a standard, high-quality manner, and ensure proper communications among providers who are working together to care for a given patient. I am sure that those of you who attended our meeting last year in Minneapolis remember the presentation by Mr. Keith Willett on how the British National Health Service cut the 30-day mortality rate in the U.K from hip fractures by 15% in just a two-year period,11 simply by making sure that the basic steps were done correctly, every time. Medicine is slowly learning lessons that aviation, building construction, and even the food industry have known for a long time, and I urge all of you to consider how these lessons can be applied to your practice.
Now, I’d like to look at trauma care from 30,000 feet, and discuss regional trauma systems. The importance of trauma centers has been demonstrated in multiple studies. For example, Dr. Ellen MacKenzie and colleagues found that similarly-injured patients who are treated at a Level-1 trauma center have improved survival and better outcomes than those who aren’t.12
In order for patients to benefit from a trauma system, they must first be able to access it. Trauma centers are of no value if the patients that need them can't get to them. Access to a trauma center should be automatic for the injured patient, without regard to socioeconomic status, insurance plan, or any other consideration. Until recently, access to trauma care has primarily been limited by the geographic distribution of trauma centers, mostly affecting the 40 million Americans who live in the rural areas of the Western United States. The increasing numbers of trauma fellows that we have trained should theoretically increase access to expert fracture care. One might think that further resources would be directed towards areas where trauma care does not exist. Indeed, more than 200 trauma centers have opened in the United States since 2009, according to Kaiser Health News.13 As this graphic shows, in Ohio the number of trauma centers doubled between 200 and 2010.14 One network alone, HCA, has opened 20 new trauma centers during this period, including a dozen in Texas and Florida alone.13 However, these new trauma centers are not located where you might think. These new trauma centers are not in underserved areas; they are established in the suburbs, where they attract paying patients, charge trauma activation fees that are higher than those at traditional safety net trauma centers, and dramatically change the demographics of the patients treated at the teaching hospital that serves as the region’s safety net. These trauma centers have been strategically placed to make money, rather than considering need. Such organizations are usually not academic or teaching institutions and they typically do not provide the resources to provide optimum care for patients with multiple- and/or complex orthopedic trauma, and but even more importantly, they are reluctant to transfer orthopaedic patients out, regardless of how complex their injuries may be.
Trauma care must be done efficiently for the sake of our society and our patients, with significant consequences if trauma centers are over- or under-utilized. Just last year, Haas et al. demonstrated the potential cost in lost lives that under-triage to trauma centers may cause, finding that initial triage to a non-trauma center is associated with at least a 30% increase in mortality in the first 48 hours.15 Conversely, over-triage increases costs and burden the centers with patients that really don’t need to be there. Trauma care is 2nd to cardiac disease in contributing to total health care costs in the United States, but much of this are wasted dollars. In a paper just published last month, Newgard and colleagues surveyed 7 US metropolitan areas and report that over a third of patients with low-risk injuries were over-triaged to Level 1 trauma centers, and that in these 7 regions, the potential increased costs of this amounted to over $130 million dollars annually.16
Regional trauma care is very complex, incorporating multiple hospitals with different capabilities. An individual hospital includes a variety of departments working together to create a whole. Like a fractal that looks the same whether you zoom in or zoom out, from 30,000 ft a trauma system looks the same as a hospital: it contains a variety of units that are coordinated into a larger whole. Just like a hospital, a successful trauma system requires financial support, coordination of care, and established medical protocols defining the attribution of patients to component centers based on severity of injury. As one might guess, achieving predictable care throughout such networks is exceedingly complex, and therefore chaotic. I have briefly mentioned the problems of over- and under-triage. A particular problem that I’ve not heard discussed and which I’d like to highlight now is what I’ll call repeated triage.
Repeated triage refers to a phenomenon that I see almost every time I take call: patients being sent from one hospital to another one that actually can’t care for the patient either, so that a second transfer is needed to a third hospital before the patient receives definitive care. It’s hard to understand how that can happen, but it does, over and over again. Trauma referrals should be like clinic: just get the patient to the right provider at the right time. That shouldn’t be difficult; that’s why we have trauma systems. However, many designated trauma centers do not have orthopedic trauma experts on their staff, or maybe only do part of the time. Or, maybe they just can’t take care of a pelvic fracture on a given day, for example. Regardless of the reason, a trauma patient simply should not be transferred to a hospital that is not prepared to take care of them. Yet, our trauma systems seem to be unable to figure this out. Just last week, I happened across a paper published in this month’s Journal of Trauma, by Clement et al.17 This article is the first I have seen that discusses the issue of subspecialty access for trauma patients, and points out the need for improved health policy interventions designed to better coordinate the field of orthopaedic traumatology.
So, when viewed from 30,000 ft., roadblocks are evident in our trauma systems that threaten access to care for many, and this is especially true for orthopedic trauma. This is an artifact of the business that medicine has become, with business interests now influencing the distribution of resources devoted to trauma care. Unlike the ideal trauma system that I described earlier, patients are often not delivered to a hospital based on the severity of injury, but instead based on what health care network they belong to. Thus, a patient with severe orthopedic injury may be taken to a hospital without the appropriate resources, even when a Level-1 trauma center is nearby. A patient with a pelvic ring, acetabular, periarticular, or open fracture should go to an institution that is specifically prepared for complex orthopedic trauma, rather than a hospital that is in network with surgeons who mainly transfer such patients out whenever they can. Let me show you some real-life examples. This patient with an isolated tibial plateau fracture was seen at 4 institutions in one day: he was referred from a rural hospital to an urban surgery center to a larger hospital that they are affiliated with, and finally to a level-1 trauma center, all in the same day. This is the problem of repeated triage taken to the extreme, and occurred in a city that most consider exemplary in health care delivery. Fortunately, other than wasting a lot of time, money, and gasoline, this patient suffered no serious consequences. Other patients may be harmed by these practices. Another real-life example is this patient with bilateral Hawkins’ III fracture dislocations who was admitted and kept in a network hospital for 2 weeks, where someone put on bilateral external fixators but left her ankles unreduced. No referral was made to either of two regional level-1 trauma centers once she was stable. She was told she should follow-up with an orthopedic surgeon once she was discharged. No recommendations were formally given to the patient about who the local or regional experts were that could care for her, or that there was even any urgency related to her injury. The patient did not receive appropriate care for a month, when she finally found her way to Dr. Sanders, who happens to work at one of the regional trauma centers near where she lived. The person she needed was there all along, but in this new paradigm, the unsuspecting and trusting patient is a commodity and paid the price when her health care networks refused to transfer care.
Examples such as these, and I am sure many of you have your own as well, resonate with us because we all know that proper care of complex extremity injury is important. Lack of integrated trauma systems with defined criteria for management of orthopedic trauma too often leads to inappropriate triage, which at the very least delays and adds to the cost of care, at worst harms patients, and certainly contributes to less certainty in outcomes. I believe that we have a large and mostly unrecognized problem in repeated triage. Despite the continued expansion in the number of trauma centers, there has been a paradoxical decrease in access to orthopedic trauma specialists and orthopedic trauma care. To improve orthopedic trauma care, we need to establish a system for triaging orthopedic trauma and allocate patients with extremity trauma to appropriate centers based on the complexity of extremity injury. Our past-president, Tim Bray and his colleagues in Reno have developed a regional system in which all of the local orthopedic surgeons partner very effectively with a modest number of fellowship-trained orthopedic trauma surgeons to provide very effective, high-quality musculoskeletal trauma care within their community.18,19 This is a win-win system for everybody: the traumatologists, the general orthopedic surgeons, and most of all the patients.
As an organization, we will need to partner with other groups, such as the American College of Surgeons and other specialties that treat extremity trauma to highlight these problems and help shine a spotlight on these issues so that policymakers take notice. We as individuals need to work with our state and local medical and orthopedic societies, and with each other, to establish protocols and procedures for the management of patients with orthopedic trauma. I hope that sounds familiar, as I circle back to the concepts of checklists and standards that I spoke of earlier. In this changing landscape of health care delivery, in which business considerations and profit motives are playing increasingly important roles, we need to be sure that our trauma systems remain intact and that medical considerations alone dictate trauma triage. We need to do it right the first time, for the sake of our patients. If care is not available at the local hospital, let’s get that person to a hospital that is capable of providing definitive care with one transfer. In his 2008 Presidential Address, Dr. Tracy Watson asked “When the Iron Men are all retired, who will pin MY hip”. The question I ask today is: If I shatter my pelvis in a car accident, will I get taken to the right hospital? Let’s do what we can to make sure that answer is yes.
I want to conclude by thanking all of the members of the OTA Board, as well as all Committee Chairs, committee members and everyone else who has contributed to this organization for their hours of service. I want to acknowledge our amazing staff in Rosemont: Darlene Meyer, our executive Director Kathleen Caswell, Alivia Payton, Diane Vetrovic, Sharon Moore, Melanie Hopkins, and Paul Hiller. The OTA could not accomplish all that we have without their able assistance. I believe that, collectively, we are the best orthopedic specialty association in North America and the best orthopedic trauma association in the world. As I look around this room, I see true heroes, and being able to serve the OTA has been the pinnacle of my career. I thank all of you for the privilege of working with you and for you.
Finally, there are a number of individuals whom I should thank, but there are too many of you to be able to mention you all. My practice partners deserve special thanks for their help over the last 20 years. My senior partners, in particular, Dick Kyle, Tom Varecka, and Dave Templeman have been incredible mentors and role models. My newest partners, Jackie Geissler and Nancy Luger sent me this picture yesterday to remind me of who has been holding down the fort this week while the rest of us are here. Unfortunately, my family could not be here today, but I need to thank my wonderful wife Jamie, and my children Michael and Katherine, for their support throughout the years. This meeting is the 22nd anniversary of my first OTA meeting, in 1991 in Seattle. At the time I was a third-year resident. My wife and then 6-week old son drove up from Portland with me, and watched me give my talk from the back of the room. It’s been quite a journey from that talk to this one, and I thank all of you for being a part of it.
Andrew H Scmidt, OTA President
References:
- Sagi HC, Ciesla D, Collinge C, et al. Synopsis of current practice patterns and a suggested evidence-based therapeutic algorithm for venous thromboembolism prophylaxis in orthopaedic trauma patients. J Orthop Trauma, in review.
- Perry DC, Parsons N, Costa ML. Surgeon level data: understanding the plot. Bone Joint J 2013;95-B:1156–7.
- Gawande A. The checklist manifesto: how to get things right. New York: Metropolitan Books, 2010.
- Ibid, p. 19.
- Treadwell JR, Lucas S, Tsou AY. BMJ Qual Saf Published Online First: 8/6/2013 doi:10.1136/bmjqs- 2012-001797.
- Teixeira PGR, Inaba K, DuBose J, Melo N, Bass M, Belzberg H, Demetriades D. Measurable outcomes of quality improvement using a daily quality rounds checklist: Two-year prospective analysis of sustainability in a surgical intensive care unit. J Trauma Acute Care Surg. 2013;75: 717-721.
- Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med 2009;360:491-9.
- Dutton RP, Cooper C, Jones A, et al. Daily multidisciplinary rounds shorten length of stay for trauma patients. J Trauma 55: 913-9, 2003.
- Stinner DJ, Brooks SE, Fras AR, Dennis BM. Caring for the polytrauma patient: is your system surviving or thriving? Am J Orthop (Belle Mead NJ). 2013;42(5):E33-4.
- Kates SL, Blake D, Bingham KW, Kates OS, Mendelson DA, Friedman SM. Comparison of an organized geriatric fracture program to United States government data. Geriatr Orthop Surg Rehab 2010;1:15-21.
- Moran CG, Wakeman R, Currie C, Partridge M; Willett KM.The National Hip Fracture Database in England, Wales, and Northern Ireland: Results from 50,000 patients treated in a 1-year period. Orthopaedic Trauma Association Annuial Meeting, Scientific Poster #27, Minneapolis, MN, Oct. 2012.
- MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of Trauma-center care on mortality. N Engl J Med 2006;354:366-378.
- Galewitz P. Boom in trauma centers can help save lives, but at what price? Kaiser Health News. Sept, 24, 2012. http://www.kaiserhealthnews.org/stories/2012/september/25/trauma-centers.aspx, accessed 10/5/2013.
- Hoholik S. Trauma-care access still an issue. The Columbus Dispatch, Dec. 26, 2010. http://www.dispatch.com/content/stories/local/2010/12/26/trauma-care-access-still-an-issue.html, accessed 10/5/2013.
- Haas B, Stukel TA, Gomez D, et al. The mortality benefit of direct trauma center transport in a regional trauma system: A population-based analysis. J Trauma Acute Care Surg 2012;72:1510-1517.
- Newgard CD, Staudenmayer K, Hsia RY, et al. The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers. Health Affairs 2013;32:1591-1599.
- Clement RC, Carr BG, Kallan MJ, Reilly PM, Mehta S. Who needs an orthopedic trauma surgeon? An analysis of US national injury patterns. J Trauma Acute Care Surg. 2013;75: 687-692.
- Bray TJ. Design of the Northern Nevada Orthopaedic trauma panel: a model, Level-II community hospital system. JBJS 83A: 283-9, 2001.
- Bray TJ, Althausen PL, O'Mara TJ. Growth and development of the Northern Nevada Orthopaedic Trauma System from 1994 to 2008: an update. J Bone Joint Surg Am 2008;90-A:909-914.