Scudder Orator: If you want to implement change, have a clear vision and be innovative

Scudder Orator: If you want to implement change, have a clear vision and be innovative

Developing solutions to complex public health problems requires establishing a clear vision, forming partnerships with knowledgeable stakeholders, and effectively communicating the goals of the plan to the general public. The 2021 Scudder Oration on Trauma—delivered Tuesday afternoon, October 26, by Lenworth M. Jacobs, Jr., MD, MPH, DSc(Hon), FACS, FWACS(Hon)—focused on three courses promulgated by the American College of Surgeons (ACS) Committee on Trauma (COT) as examples of how structured processes and targeted communication can have a significant effect on the care of the injured patient. Dr. Jacobs is professor of surgery and professor of traumatology and emergency medicine, University of Connecticut; director, Trauma Institute at Hartford Hospital, CT; and ACS Medical Director, STOP THE BLEED® (STB).

Specifically, Dr. Jacobs described the “reproducible method for successfully implementing” the following COT courses: Ad­vanced Trauma Life Support (ATLS®), Advanced Trauma Operative Management (ATOM), and STB.

In the lecture, Trauma, Education, Communication and Implementing Change, Dr. Jacobs summarized the driving force for establishing the ATLS course—James K. Styner, MD, FACS, who had been involved in a plane crash in a Nebraska cornfield in 1976. Dr. Styner was dissatisfied with the quality and timeliness of care he and his family received in the hours subsequent to the crash. To address these inadequacies, Dr. Styner joined forces with Ronald Craig, MD, a family medicine physician in Lincoln, NE, to develop a program that would equip physicians and surgeons who infrequently see advanced trauma patients with the skills and training needed to provide lifesaving care to severely injured patients.

“The vision for the initial ATLS course in 1978 was that it should be educational, engaging, and practical, which is to say that you could take these skills and employ them immediately,” Dr. Jacobs said. “[The course featured] standardized lectures and taught relevant, essential skills that would make a difference in resuscitating trauma patients. Standardized resuscitation was easy to teach and in two days you would be competent in trauma resuscitation. This rapidly became a requirement for resident education and a requirement for trauma center certification,” he said.

The ATLS implementation strategy included identifying key partners, such as national trauma experts; communicating results at the COT meeting; and publishing processes and outcomes related to trauma resuscitation.

Moving from resuscitation to the operating room (OR), Dr. Jacobs noted that “any surgeon should be able to identify an injury, control it, figure out the severity, and determine the surgical treatment protocol. That is the standard expectation of the public for any surgeon that is going to be taking care of them.”

The issue had to do with technical competence. In the 1970s, he noted, surgery residents were expected to have performed 1,200 to 1,500 operations to graduate, whereas in 2000 that number dropped to 750 to 850 operations. “[In the early 1990s,] the American Board of Surgery was only requiring 10 trauma operating procedures to be certified as a competent trauma surgeon. We noticed there was a decreased knowledge in examinees as to how to deal with severe trauma injury,” Dr. Jacobs said.

The vision for the ATOM course was a one-day experience with six 30-minute lectures; 12 operations on a 50kg ovine or porcine; and pre-course preparation that included pretest, textbook, and video components and a post-course evaluation.

“We wanted to create an environment for the student that wasn’t simply like an operating room—it was an operating room,”  Dr. Jacobs said, noting the course featured similar audio and visual cues found in an OR, standard OR instrumentation, and scenarios that were built from real-world scenarios.

As the ATOM course evolved and expanded throughout the U.S.—meeting its objective of increasing surgeons’ experience in managing penetrating trauma to the abdomen and chest—surgical colleagues from around the world expressed interest in implementing the course. Specifically, the West African College of Surgeons petitioned the ACS to provide an effective hands-on learning experience for surgeons in the region, which would involve the development of a surgical skills simulation laboratory at the University of Ghana and the Korle-Bu Hospital in Accra, Ghana. This endeavor would require the acquisition of anesthesia equipment, surgical instruments, and the creation of multiple surgical operating suites in the skills center, according to Dr. Jacobs. A group of senior ATOM instructors from the ACS COT traveled to Ghana to implement two training courses in the Ghana skills center, and subsequently the center has trained more than 100 surgeons.

Following the success in West Africa, international ATOM train­ing sites were implemented in Qatar and Saudi Arabia. Sites also were established in São Paulo, Brazil, multiple countries in Europe, and Japan.

In the wake of the December 2012 Sandy Hook Elementary School shootings in Newtown, CT, Dr. Jacobs assembled a team of government and health care leaders to form the Hartford Consensus, the mission of which was to develop policies that would enhance survival of the victims of mass-casualty events.

“A delay in stopping severe bleeding increases morbidity and mortality. So, our first order of business was identifying who is responsible for stopping exsanguination, and once we identified that, how we could implement a plan that allows the responsible party to act immediately to control bleeding,” Dr. Jacobs said. He cited the need for sourcing credible data on active shooter events, specifically from the U.S. Federal Bureau of Investigation and the U.S. Department of Justice between 2000 and 2013, to gain initial support for the Hartford Consensus and its future initiatives.

Propelled by the support of the U.S. federal government in the form of a Presidential Directive issued by then-President Barack Obama—which underscored the goal of enhancing security and resilience by developing systematic preparation for threats to public health and safety—the Hartford Consensus, in collaboration with the ACS, moved forward with the national STB program.

“Before launching a national training course, it is important to assess the public’s interest in participating in this kind of training,” Dr. Jacobs said, noting that a national polling organization was commissioned to assess the public’s response to the idea of being trained to stop severe bleeding. Of the 1,051 people sur­veyed, 98 percent said they were very likely or somewhat likely to stop bleeding if a family member was injured; 92 percent said they would get involved despite not knowing the person; and, 94 percent said they would provide care if it were safe to do so in an active shooter event.

The Hartford Consensus, together with its partners, worked to develop a communication and marketing strategy to promote the STB Program. “If you want to keep the blood in the body, the people who are there are very important,” Dr. Jacobs said, stressing the need for developing a simple and clear communication plan in order to engage individuals who are not medical personnel. “We discovered that words are not as effective as visual messages. You want to make the problem and the solution obvious to the public.”

According to Dr. Jacobs, training voluntary immediate responders to manage a severe bleeding incident was an important first step, but providing them with access to readily available bleeding control equipment was also essential to improve survival during these events.  After consulting with military experts to determine minimum requirements for civilian bleeding control kits, the kits were placed in public places, often near external defibrillators in schools, hospitals, airports, stadiums, and so on.

The Bleeding Control Basic Course has been imple­mented in all 50 states and 127 countries. More than 115,400 classes have been offered, and nearly 1.8 million people have been trained and certified by the ACS as immediate responders in severe bleeding incidents.

“Change has been implemented through education, communication, and innovation. The steps, which are reproducible, are: identity the problem, develop a vision of the solution, engage in partnerships, implement the solution, and communicate the results. Remember, no problem is too big for a solution,” Dr. Jacobs said.

This and other Clinical Congress 2021 sessions are available to registered attendees for on-demand viewing for a full year following Congress on the virtual meeting platform.

For a detailed discussion of this session, view an interview with Dr. Jacobs. Conducting the Clinical Congress Daily Highlights interview is Joseph V. Sakran, MD, MPH, MPA, FACS, director of emergency general surgery, associate professor of surgery, and associate chief of the division of acute care surgery, The Johns Hopkins Hospital, Baltimore, MD.