|Prevention Guidelines for ACS Verified Trauma Centers|
Resources for Optimal Care of the Injured Patient outlines the resources necessary for optimal care and is used as a guide for the development of trauma centers throughout the United States. It is the document by which trauma centers are reviewed by the ACS-approved site surveyors.
'The Guide outlines requirements for Level I centers and reccomendations for Level II-IV centers with regard to their prevention programs. Below is the text from Chapter 18 of the Guide:
Despite decades of progress in the development of trauma centers and trauma systems, injury remains the leading cause of years of potential lives lost and leaves millions of Americans chronically disabled every year. The overall cost impact estimates for intentional and unintentional injuries now approach half a trillion dollars a year.Medical costs of injury account for 12 percent of national health care expenditures. The financial, physical, and emotional impacts touch every home, school, and workplace in all of our communities.
Perhaps the most challenging aspect of the burden of injury is that it is largely preventable. Almost all other major causes of death and disability have extensive detection, intervention, and prevention programs that are well funded by public and private sources. Injury prevention efforts receive far less attention and resources than do prevention efforts focused on cancer, cardiovascular disease, and a variety of other groups of diseases. In comparing preventability with resource commitment, injury prevention efforts are often neglected, receiving far less funding than other disease prevention programs. The need for effective action and advocacy could not be more compelling.
Trauma centers must have an organized and effective approach to injury prevention and must prioritize those efforts based on local trauma registry and epidemiologic data (CD 18–1). Physicians, nurses, and other trauma center personnel have unique perspectives and equally unique opportunities to focus community efforts on effective prevention programs and, perhaps most important, to partner with injury prevention experts and resources in the community. This collaboration leads to an exchange of data and ideas that allows better analysis of the problem and its solutions.
Injury prevention is the responsibility of all trauma team members working in collaboration with the community. The organization of these efforts begins with effective leadership. Each trauma center must have someone in a leadership position who has injury prevention as part of his or her job description (CD 18–2). In Level I centers, this individual must be a prevention coordinator (separate from the trauma program manager) with a job description and salary support (CD 18–2). In Level II, III, and IV centers, this position may be filled by a trauma program manager with a specific role in prevention efforts detailed in the job description, but only if this role does not negatively affect the work product of the trauma program manager. Trauma medical directors should have a demonstrable role in injury prevention. It is also highly desirable that other trauma physicians and nurses actively participate in injury prevention efforts at Level I, II, III, and IV centers.
Effective injury prevention begins with a focus on the most common causes of injury in the community. These causes include contributing factors such as drug and alcohol abuse and behavioral health problems. The same causes are often linked with the most common mechanisms of injury presenting to the trauma center. The trauma center injury prevention program should identify the three most common causes of injury or traumatic death at the trauma center or in the community using the trauma registry or other available epidemiologic data. Program and intervention strategies then should be selected based on these data.
Traditionally, prevention efforts have focused on education, enactment and enforcement, and environmental modification. Educational prevention strategies assume that the target audience is motivated and ready to change risk-taking behavior. The essential elements of an effective trauma center injury prevention program are described in Table 1.
The local or state vital records and medical examiner’s reports describing causes of death, along with the data available from local and state police, help identify the incidence of injuries and high-risk behaviors. These agencies identify injuries in a manner that is often not available using the trauma registry. For instance, in many communities, suicide is one of the leading causes of nonnatural death but may not be one of the most common mechanisms leading to trauma center admissions. The trauma medical director and trauma program manager should establish a close working relationship with their local medical examiner to secure information regarding causes of traumatic death upon which injury prevention efforts can be based.
Part of every effective injury prevention effort is a focus on proximate causes. Many injuries have alcohol and drug use as an important contributing factor. Screening and brief intervention for alcohol use are required of all trauma centers. Access to firearms is another important root cause of traumatic injury. Socioeconomic and cultural, environmental, and engineering factors should also be considered. For instance, a high incidence of elderly pedestrians struck by automobiles may result from the interplay of multiple factors in certain neighborhoods in a community. Domestic violence is also linked to a variety of important contributing factors. Identifying these key contributing factors can generate opportunities to choose effective prevention programs that fit a community’s needs.
It has been demonstrated that trauma centers can use the teachable moment generated by an injury to implement an effective injury prevention strategy; alcohol and/or drug abuse counseling for patients presenting to the hospital because of a substance abuse–related injury is an example of such an opportunity. Alcohol is such a significant associated factor in, and contributor to, injury that it is vital that trauma centers have a mechanism to identify patients who are problem drinkers.
Universal screening for alcohol use must be performed for all injured patients and must be documented (CD 18–3). At Level I and II trauma centers, all patients who have screened positive must receive an intervention by appropriately trained staff, and this intervention must be documented (CD 18–4). Epidemiologic data suggest high rates of problematic drug use among trauma patients who screen positive for alcohol use. Best practices include implementing screening procedures that capture drug use co-morbidity and appropriate treatment referral. The incorporation of routine screening and trauma center–based intervention for drugs of abuse is an area that could benefit from targeted research.
Programs selected for trauma center injury prevention efforts should be proved and promising programs that have been used at other trauma centers or in other relevant settings. Before embarking on an injury prevention program, a complete review of the literature and existing programs should be undertaken to ensure that programs with proved efficacy are selected. There are many examples of successful programs from local, regional, and national efforts by a variety of organizations. Lessons learned in implementing programs by adapting them to the local community invariably strengthen existing programs. Information regarding prevention programs and resources is available through the Centers for Disease Control and Prevention (www. cdc.gov), other trauma centers, and numerous professional organizations.
Level I and II trauma centers must implement at least two programs that address one of the major causes of injury in the community (CD 18–5). A trauma center’s prevention program must include and track partnerships with other community organizations (CD 18–6). Law enforcement agencies, schools, churches, county health departments, and a variety of other organizations are often willing partners in injury prevention. As part of its participation in community-based injury prevention efforts, the trauma center should keep track of the external partnerships created. Many of these community partners have staff members with the time and expertise to effectively work in the community, and some of these organizations have injury prevention as a part of their core mission. Partnering with these organizations will allow trauma center personnel to quickly connect with community members in prevention efforts. Effective injury prevention is best accomplished through shared ownership, with multiple partners in the community working together. The trauma center injury prevention program should provide a periodic report of prevention activities, partners in the prevention efforts, and the estimated number of community members who received these services for each program implemented.
In its prevention program, the trauma center can also link with a wide variety of regional and national prevention efforts. These efforts include both government agencies and nongovernment organizations. The prevention program should join in these efforts and keep track of collaboration with these organizations and the resulting prevention efforts.
Focused and judicious cooperation with print and broadcast media also can enhance prevention opportunities.
At some point in a trauma center’s prevention program development, an opportunity to work with local elected and appointed officials and to promote effective prevention legislation will arise. Most trauma centers have a government liaison who can be the initial point of contact when dealing with elected officials. Whenever possible, this person should establish contact with these officials, maintain a good working relationship, and advance pertinent advocacy positions. Participation in advocacy for injury prevention legislation should be a priority.
Table 2 outlines a suggested format for recording and reporting prevention activities.'