Timely orthopaedic response critical for ACS verification

Authored by:
Kristy Ruiz, MHA, BSN, RN, CEN
Senior Advisor

The American College of Surgeons (ACS) recently presented statistical data demonstrating how trauma centers are faring in their verification and reverification journey under the new 2022 Gray Book. It has been reported that only 45 percent of centers have been verified for the three-year cycle under the new standards. These results have many centers scrambling to understand the changes and how they can successfully navigate the new standards.

Among the Top 10 common opportunities for improvement and verification barriers is timely orthopaedic surgeon response in compliance with ACS Standard 5.21. The new standard includes both the expectation, and the measures of compliance. In all trauma centers, an orthopaedic surgeon must be at bedside within 30 minutes of request for the following: 

• Hemodynamically unstable, secondary to pelvic fracture
• Suspected extremity compartment syndrome
• Fractures/dislocations with risk of avascular necrosis (e.g., femoral head or talus)
• Vascular compromise related to a fracture or dislocation
• Trauma surgeon discretion

The orthopaedic surgeon must be involved in the clinical decision-making for the care of these patients, and compliance is evaluated from the time of request until the surgeon’s arrival at the bedside.1 The ACS allows some leeway by permitting an orthopaedic surgery resident or advanced practice provider (APP) to act as a consultant, provided there is documented communication with the attending orthopaedic surgeon.

This process is further complicated by the fact that single-system orthopaedic trauma injuries do not always meet trauma activation criteria, making a timely response, once the injury is identified, even more essential. Documentation of both the consult request and arrival is key. To effectively demonstrate compliance with the timely response, both the orthopaedic provider and the requesting provider (typically emergency medicine or trauma surgery) must document the time of request and the presence at the bedside within the required timeframe.

Validation often requires trauma registrars to sift through records to find the documentation supporting your center’s compliance with the standard. When documented, these times are often buried within dictation notes, making it difficult to pull them into most registry software for process improvement (PI) review. Some may not be documented at all, and delayed dictation makes accurate data capture impossible to verify.

This standard is not new. In the 2014 Orange Book, chapter nine focused on orthopaedic care. Previously, the orthopaedic surgeon was required to be available in the trauma resuscitation area within 30 minutes after consultation was requested by the surgical trauma team leader for multiply injured patients (CD 9-7), based on institution-specific criteria.

Hospitals were previously expected to create their own compliance standards. Now, the standard is clear, and the ACS is verifying compliance with timeliness through the Pre-Review Questionnaire (PRQ) before the site survey. The new PRQ requires the following:

  1. A report of orthopaedic surgeon response times over the Reporting Period for patients meeting the criteria outlined in the standard.2
  2. Uploading the relevant policy that outlines the criteria and requirements for orthopaedic surgeon response times.2

This level of detail is a theme in the new PRQ, but do not panic. Start taking action now. 

  • Begin by educating your team on the requirements
  • Discuss the new criteria at your operations, and multi-disciplinary meetings
  • Collaborate with your dedicated orthopaedic liaison and hospital informatics team to create templates or dot phrases within the medical record to assist providers in documentation compliance
  • Validate the process with your Performance Improvement and registry teams to ensure accurate data capture
  • Run reports from the trauma registry to assess missing data points to reinforce the new process 
  • Consider hospital specific QA tags for the PI team to track and trend your progress

The new standard presents a challenge, but with focus and a dedicated and engaged orthopaedic liaison, your trauma center can overcome it. By concurrently reviewing charts to ensure both care and documentation meet the mark, success is within reach.

  1. Resources for Optimal Care of the Injured Patient, 2022 Standards
  2. American College of Surgeons Pre-Review Questionnaire