Why I still talk about the ACS Orange Book

Authored by:

Angie Chisolm, MBA/HCM, BSN, RN, CFRN, TCRN
President

During a recent webinar on trauma performance improvement, I referenced several passages from the 2014 edition of Resources for Optimal Care of the Injured Patient — commonly and affectionately known as the “Orange Book”. 

This was a source of confusion for some people who attended the webinar. As everyone in trauma knows, the American College of Surgeons (ACS) replaced the Orange Book with the “Grey Book” in 2022.

Quite understandably, a few people asked, “If the Orange Book is no longer in force, why is Angie Chisolm still talking about it?”

Here is my thinking:

First, yes — trauma centers that are verified by the ACS must comply with the 2022 standards, not the 2014 standards. So trauma program leaders need to know the Grey Book inside and out and give it their complete focus.

In addition, let me go on record as saying that the Grey Book is a big improvement in clarity and conciseness. So it is a welcome change for anyone who has ever combed through the Orange Book trying to understand exactly what the ACS requires.

However, I think everyone can agree that in streamlining the standards document, the ACS left out a lot of useful information on trauma program management that remains relevant.

In particular, the Orange Book contains a lot of practical guidance on trauma PI, especially in its explanation of “why we do what we do”.

• For example, Chapter 16 of the Orange Book provides an overview of key PIPS program concepts and the importance of the registry in the PI process. It explains that PI is expected to be a continuous process of measuring, evaluating and improving care that reduces unnecessary variation in care and prevents adverse events. (See page 114 under “Operational Concepts”.)

• Chapter 16 also explains the reason for peer review and systems committee meetings. “The trauma program’s scope of performance evaluation extends from institution-wide variables (process review) to measures of individual practitioner performance (peer review).” Based on some key wording in the current prereview questionnaire (PRQ), trauma programs still need to have a “operations/systems” committee. However, I still get questions from trauma program managers about whether the system meeting is required because it isn’t clearly stated in the 2022 standards.

• “The determinants of how well a trauma center performs include variables that can be influenced (such as efficacy, safety, or cost of care) and variables that cannot be influenced (such as the severity of injury or preexisting co-morbidities).” This is probably the most overlooked but impactful sentence in Chapter 16 because it describes the reason for performing PI activities. We are always looking to reduce variations in care that can be controlled and that impact patient outcomes.

These perspectives and guidance are truly invaluable. So even though the 2014 standards are no longer current, it’s clear to me that everyone in trauma can still learn a lot from the Orange Book.

In fact, whenever I am mentoring a new trauma program manager, I go back to the Orange Book to help them get the basic “why” and “how” perspectives that are still relevant today.

See what you think.

As I mentioned, this issue came up during a recent webinar. If you would like to learn more, I invite you to view Trauma PI Strategy: Leveraging “Case Review vs. Aggregate Review” for More Efficient Loop Closure.