PTS 2015 PRESIDENTIAL ADDRESS
Alone we can do so little, together we can do so much Richard A. Falcone, Jr., MD, MPH, Cincinnati, Ohio
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hank you Bob for that wonderful introduction and the sharing of my childhood photos. Thank you all for being here at our second annual meeting of the Pediatric Trauma Society and making it such a wonderful meeting. As the title of my address suggests, none of us accomplish things completely alone, and the opportunity to serve as your president this past year is no exception. Although I have been fortunate to have a strong list of mentors throughout my life, training, and surgical career, I will highlight here those who have been my Pediatric Trauma Society partners and mentors. Four key mentors have been the presidents who came before me and the one who is about to follow me (Fig. 1). First, David Mooney, MD; without David’s vision, none of us would be sitting here at a national multidisciplinary pediatric trauma meeting. I, like several others in this room, was fortunate to be part of some early discussions with David at an Eastern Association for the Surgery of Trauma meeting. The concept of having a ‘‘home’’ for those of us who care for injured kids and share a desire to continually improve what we can do to keep kids safe, get them well after an injury, and get them back to their full potential, was much needed and inspirational. As our first president, he set the foundation and has been a friend and mentor to me as we all have moved the organization forward. Next is Lynn Haas, RN, MSN; I am fortunate that Lynn has been my trauma program manager as well as our organization’s second president. Lynn has taught me more than she knows about how to run a trauma program, and I know she has shared similar knowledge selflessly with many in this room and beyond. As our second president, Lynn had the unenviable task of leading the creation of our bylaws, a critical job and one that she was much better suited to accomplish than any of the surgeon leaders to date. Our third president was Barbara Gaines, MD; Barb led us through our first national meeting, a huge step in establishing our foothold as a true national organization. During her time, we became recognized as a national trauma organization by the American College of Surgeons’ Committee on Trauma and began our partnership with The Journal of Trauma and Acute Care Surgery. I have learned a lot from Barb’s leadership and friendship. Finally, our incoming President Robert Letton, MD; Bob has become a good friend and mentor during that last several years, and I am confident that our organization is in great hands and will continue its amazing growth under his leadership. Anyone who has ever been fortunate enough to lead an organization, big or small, will surely tell you, as a leader, you are only as good as those board members, committee chairs, and committee members who do the real work of the organization. I am certainly no different and will take just a moment to recognize our executive board members and committee chairs (Fig. 2). Our board, Bill Millikan, MD, secretary; Lisa Gray, RN, MSN, member at large; Terri Elsebernd, RN, MSN, member at large; Bob Letton, MD, president-elect; and our three departing board members, Laura Cassidy, PhD, member at large; Pina Violano, RN, MSN, treasurer; and Barb Gaines, MD, past president. Our committees did some amazing work this year and were led by the following committee chairs: Margot Daugherty, RN, MEd, program chair; Kathy Haley, RN, MSN, membership chair; Leann Wurster, RN, and Garret Free, EMT, marketing and technology chairs; John Petty, MD, guideline chair; Diane Hochstuhl, RN, MSN, education chair; and Matt Borgman, MD, and Rita Burke, PhD, research chairs. Finally, I certainly would not be here without my family. My grandparents, parents, and stepparents, mother-in-law, siblings, and of course, my wife Kelly and our three amazing children Chase, Calista, and Halle, your support and love are what motivates me. Now, on to the title of my talk, ‘‘Alone we can do so little, together we can do so much.’’ This Helen Keller quote seemed perfectly fitting to what I believe describes the future of the Pediatric
From the Comprehensive Children’s Injury Center, Division of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. This address was presented at the 2nd annual meeting of the Pediatric Trauma Society, November 6Y7, 2015, in Scottsdale, Arizona. Address for reprints: Richard A. Falcone, Jr., MD, MPH, Division of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229; email: [email protected]. DOI: 10.1097/TA.0000000000000965
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J Trauma Acute Care Surg Volume 80, Number 5
PTS 2015 Presidential Address
Figure 1. Presidents of the Pediatric Trauma Society. A, David Mooney, MD, MPH. B, Lynn Haas, RN, MSN. C, Barbara Gaines, MD. D, Robert Letton, MD.
Trauma Society. Despite Helen Keller’s multiple handicaps, she was able to achieve more than anyone thought possible and became an advocate for handicapped individuals everywhere. Although she was an incredibly motivated and strong woman, she realized she never could have achieved what she did without working together with others. I know there are a lot of amazing individuals in this room who work hard every day to improve the outcomes for injured children, but more importantly, I believe that by coming together and working together we can accomplish amazing things, moving forward for injured children and their families. When most people think about teamwork, their first thought goes to successful sports team. For me and in my home, those that come to mind are the New York Yankees, the New York Giants, and the Cincinnati Reds and Cincinnati Bengals; fortunately, the New York and Cincinnati teams that we cheer for are not in the same divisions and do not play head to head often! This view of teamwork inspires thoughts of athletes working together to play as a unit and win championships. According to Wikipedia (accessed November 2015), in health care, teamwork is a dynamic process involving two or more health care professionals with complementary background and skills, sharing common health goals and exercising concerted physical and mental effort in assessing, planning, or evaluating patient care. This explains what we do during a trauma resuscitation every day. There is perhaps no place like the trauma
resuscitation bay when a severely injured child arrives, who requires a group of people to come together with varied backgrounds and skills to work as a team to ensure the highest level of safe and high-quality care. Realizing the crucial role that teamwork and team communication play in caring for an injured child, especially during the acute resuscitation, 10 years ago, we began our multidisciplinary pediatric trauma simulation program. The goal of our program was to train as a team using high-fidelity simulators to improve our ability to communicate with each other, appreciate each other’s contribution to care, work better together to identify problems, and most importantly, improve safety and quality of care provided to injured children. Through this training, we have been able to demonstrate improvements in completion of key tasks, identify latent safety threats before reaching a patient, and continually train, evaluate, and improve our team function.1Y4 There are many others in this organization who have used simulation to learn and improve our trauma teamwork/performance during a resuscitation, and working together, we can move even further and beyond the doors of our trauma centers.5,6 Another key concept to allow the Pediatric Trauma Society to move care and outcomes for injured children forward is collaboration. A useful definition of collaboration is that it is the act of working with someone to produce or create something. Think of your favorite musical group, perhaps, the Beatles or the Dave Matthews band. Both groups are made up
Figure 2. Executive board. A, William Millikan, MD, secretary. B, Lisa Gray, RN, MSN, member at large. C, Terri Elsebernd, RN, MSN, member at large. D, Laura Cassidy, PhD, member at large. E, Pina Violano, RN, MSN, treasurer. 686
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of extremely talented individuals, but when they collaborate to make music, they create something better than any one of them could do on their own. The business world has been far ahead of health care in truly appreciating the value of collaboration. There have been countless books written on the topic of collaboration in business, and a recent review of several of these was recently published in the Harvard Business Review, ‘‘Collaborate for Real’’ (September 2015). In this article, they state that any business works better when its employees, teams, divisions, and leaders share ideas and resources to pursue a common goal. One example of failed collaboration they provide is one many of us of a certain age can certainly relate to. Many of us likely had our cherished Sony Walkman and our collection of cassette tapes. In the 1980s, the Sony Walkman dominated the market, but what happened to the Walkman that now leads my children to look at me with a quizzical look when I mention it? In the book The Silo Effect,7 the author describes how Sony missed the digital music revolution because its competing divisions could not agree on products, platforms, or strategy. As a consequence, the Sony Walkman is now a memory, and most of us carry around our music on our Apple or Android product carrying more music than our cassette-carrying case ever could have held. For the sake of the thousands of pediatric trauma patients who are cared for, we need to collaborate better. Although many of us in this room do work hard to break out of our silos, trauma care remains too siloed. There is the prehospital, emergency medicine, surgery (general/orthopedic/ neurosurgical), critical care, rehabilitation, and research silos. There is also a silo that crosses all of these but still at times is its own silo, patient services and social services. Fortunately, each of these silos is represented in the membership of the Pediatric Trauma Society, and I have been excited to see that so much communication across these silos is occurring at this meeting. Again learning from the business world, here are some keys to successful collaboration that we need to keep in mind. First, keep organizational boundaries flexible and fluid. Next, use technology to disrupt boundaries when they do exist. Third, share data, and let different interpretations be heard. Fourth, and in my opinion the most important, build trust by showing warmth and competence, appreciating others’ perspectives and revealing vulnerability. As I reflect on the last 4 years of our young organization and the last day and a half of this meeting, I am excited to say that I see each of these keys being exemplified. So how does collaboration in health care work beyond an organization’s annual meeting? When I attended the Harvard School of Public Health after completing my pediatric surgical fellowship, I had the opportunity to hear the ideas of Michael Porter for redefining health care. Michael Porter is well-known in the business world, but before him and his coauthor Elizabeth Olmstead Teisberg wrote Redefining Health Care,8 they were unknowns in the world of health care. In this book, they challenge the traditional specialty-based silo approach to health care. They argue that patients do not particularly care which subspecialist they see for their cardiac disease, inflammatory bowel disease, or any other ailment; patients want their problem cared for seamlessly, safely, and of high quality. They provide an argument and some examples from the Cleveland Clinic of how by working across silos, with a focus on a disease entity, outcomes could be improved, safety increased, and costs decreased. Imagine
the advances that could occur in trauma care if we did not have our ‘‘home’’ silos. In the research world, the Pediatric Emergency Care and Research Network (PECARN) is an example of a successful collaboration across numerous emergency departments. First funded by the Emergency Medical Services for Children in 2001, PECARN now has 18 hospital emergency department affiliates, 6 EMS affiliates, with 6 research nodes, an EMS node, and a data coordinating center. As a result of this collaborative network, more than 86 peer-reviewed multicenter articles have been published. Much of the funded work of PECARN has focused on the evaluation of pediatric trauma patients and influence the way we care for injured children.9Y13 When looking to improve patient safety, the Children’s Hospitals’ Solutions for Patient Safety is a leading collaborative example. This collaborative, now composed of more than 80 children’s hospitals, has shared goals of harm reduction including a 40% reduction in hospital-acquired conditions, 10% reduction in readmissions, and a 25% reduction in serious safety events. Since 2012, it is estimated that through the collaborative work, 4,746 children have been spared of serious harm with an estimated savings of $92 million (www.solutionsforpatientsafety.org). When looking at trauma in particular, an important collaborative to improve trauma care has been the American College of Surgeons’ Trauma Quality Improvement Program (TQIP) and the more recent Pediatric TQIP. The goal of TQIP is to elevate the quality of care for trauma patients by using risk-adjusted benchmarking, providing education on how to improve data quality, and how to accurately interpret your data and by providing opportunities to network and share information about best practices. At Cincinnati Children’s, we have developed a collaborative we call the Pediatric Trauma Transformation Collaborative (PTTC). The PTTC was initially developed in 2008 when at the suggestion of Dr. David Tuggle, a pediatric surgeon and American College of Surgeons site reviewer, the leadership of St. Mary’s Medical Center in Evansville, Indiana, came to meet with the trauma program leadership at Cincinnati Children’s to see how the two hospital might partner to improve pediatric trauma care. St. Mary’s had been a Level II adult trauma center with added qualifications in pediatrics, but when this verification status disappeared in 2006, they could not meet verification requirements as a Level II pediatric trauma center. Out of these initial meetings and the appreciation that more than 17 million children do not have access to pediatric trauma centers, we sought to develop a program to support hospitals committed to improving the care of injured children in their regions. The goal was to help provide a high quality of care in regions of need and to reduce the need to transfer injured children away from their families and support systems. The collaborative program includes the participation in monthly trauma performance improvement meetings by a pediatric surgeon from our experienced Level I pediatric trauma center, pediatric trauma guideline development and support, provision of pediatric trauma focused Continuing Medical Education/Continuing Education Unit opportunities, pediatric trauma multidisciplinary simulation training, and peer-to-peer support among physicians, nurses, program managers, registrars, and others as needed. Since its inception, we have now also partnered with Parkview Regional
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Medical Center in Fort Wayne, Indiana, and Sanford Health in Fargo, North Dakota. As a result of the collaboration, all three sites are now verified American College of Surgeons Level II pediatric trauma centers; they have had increased patient volumes and decreased transfer rates; and they have expanded their portfolios of performance improvement initiatives and have demonstrated reductions in imaging and length of stay of children with solid organ injuries.14 Finally, at our institution, we realized that there was an incredible amount of talented individuals working on pediatric injury prevention and care but we were not very well aligned and were living in silos most of the time. As a result, we began what is now the Cincinnati Children’s Comprehensive Children’s Injury Center (CCIC). This has served to bring together the silos of injury prevention work in our emergency medicine division and trauma surgery as well as bring together diverse multidisciplinary providers to develop a multidisciplinary head injury clinic and develop cross-divisional research projects. I am incredibly proud of the 12 articles we have at this meeting, not simply because of the number but also because nearly all of them represent collaborative efforts across traditional silos. At this same meeting last year, we shared how our collaborative injury prevention approach, along with community partnerships, resulted in the development and implementation of a volunteer-driven home safety bundle that has resulted in population-based injury reductions for children younger than 5 years in our community. Before the collaborative work, we each had small and sometimes fleeting impact on the injury problem in our community. Another collaborative and community partnership injury prevention program that many of you have been involved in is our Buckle Up for Life program (www.buckleupforlife.org). This program works through a partnership of children’s hospitals with community organizations to increase child restraint use among high-risk populations. During the past 10 years, the program has been implemented through 13 hospitals and 167 community organizations across the country. At the sites where the program has been implemented, the rate of children unrestrained in cars decreased from 1 in 4 to less than 1 in 10; the rate of children in car seats increased from only 1 in 3 to 1 in 2; and although not a focus of the program, there was a 15% increase in the use of seat belts by adults as well. This brings me back to this organization and the thought of what we can do together. In just four short years, we have grown to more than 550 members, including 15 international members and including nurses, researchers, program managers, prehospital providers, surgeons from several disciplines, emergency medicine physicians, child abuse experts, rehabilitation specialists, as well as students and residents. We are here at only our second annual meeting with nearly 300 people registered and more than 60 wonderful articles. We have maintained a strong partnership with the Eastern Association for the Surgery of Trauma, a key organization that helped foster our early development. We now have a quarterly member newsletter, are active in guideline development and sharing, provide our members with access to online educational opportunities, have developing research partnerships, and have obvious networking across traditional silos as evidence at this meeting alone. 688
So how do we now go from good to great? The Pediatric Trauma Society needs to be the voice of the injured child worldwide. We need to be the forum where the best in pediatric trauma research is shared and nurtured. The Pediatric Trauma Society needs to be the organization that defines the direction of pediatric trauma related policy. The Pediatric Trauma Society needs to become the leading organization for pediatric traumarelated education. This needs to be through our annual meeting, through a robust online education platform, and by supporting the pediatric trauma education among our adult trauma organizations. I am confident that we will get there by continuing to appreciate the value in our intellectual diversity and supporting the excitement and energy of the new ideas we share. Thank you for the privilege of having served as your president, and continue to ask yourselves, ‘‘What can we make possible together?’’ REFERENCES 1. Falcone R, Daugherty M, Schweer L, Patterson M, Brown R, Garcia V. Multidisciplinary pediatric trauma team training using high fidelity trauma simulation. J Pediatr Surg. 2008;43(6):1065Y1071. 2. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2013;22:468Y477. 3. Patterson MD, Geis GL, LeMaster T, Wears RL. Impact of multidisciplinary simulation-based training on patient safety in a paediatric emergency department. BMJ Qual Saf. 2013;22:383Y393. 4. Couto TB, Kerrey BT, Taylor RG, FitzGerald M, Geis GL. Teamwork skills in actual, in situ, and in-center pediatric emergencies: performance levels across settings and perceptions of comparative educational impact. Simul Healthc. 2015;10:76Y84. 5. Parsons SE, Carter EA, Waterhouse LJ, Fritzeen J, Kelleher DC, O’Connell KJ, Sarcevic A, Baker KM, Nelson E, Werner NE, et al. Improving ATLS performance in simulated pediatric trauma resuscitation using a checklist. Ann Surg. 2014;259:807Y813. 6. Weinberg ER, Auerbach MA, Shah NB. The use of simulation for pediatric training and assessment. Curr Opin Pediatr. 2009;21:282Y287. 7. Tett G. The Silo Effect: The Peril of Expertise and the Promise of Breaking Down Barriers HardcoverVSeptember 1, 2015. New York, NY: Simon and Schuster; 2015. 8. Porter M, Olmsted Teisberg E. Redefining Health Care: Creating ValueBased Competition on Results. Boston, MA: HBR Press; 2006. 9. Garnett J, Harwayne-Gidansky I, Ward M, Critelli K, McLaren S, Ching K. 215: the PECARN head trauma rule: validating a clinical decision tool. Crit Care Med. 2015;43:55. 10. Faris G, Byczkowski T, Ho M, Babcock L. Prediction of persistent postconcussion symptoms in youth using a neuroimaging decision rule. Acad Pediatr. 2015. [Epub ahead of print]. 11. Mahajan P, Kuppermann N, Tunik M, Yen K, Atabaki SM, Lee LK, Ellison AM, Bonsu BK, Olsen CS, Cook L, et al. Comparison of clinician suspicion versus a clinical prediction rule in identifying children at risk for intra-abdominal injuries after blunt torso trauma. Acad Emerg Med. 2015;22:1034Y1041. 12. Holmes JF, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P, Adelgais K, Ellison AM, Yen K, Atabaki S, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;62:107Y116.e102. 13. Nigrovic LE, Lee LK, Hoyle J, Stanley RM, Gorelick MH, Miskin M, Atabaki SM, Dayan PS, Holmes JF, Kuppermann N, et al. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Arch Pediatr Adolesc Med. 2012;166:356Y361. 14. Falcone R, Milliken W, Bensard D, Haas L, Daugherty M, Gray L, Tuggle D, Garcia V. A paradigm for achieving successful pediatric trauma verification in the absence of pediatric surgical specialists while ensuring quality of care. J Trauma Acute Care Surg. 2016;80:433Y439.
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Alone we can do so little, together we can do so much Richard A. Falcone, Jr., MD, MPH, Cincinnati, Ohio
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hank you Bob for that wonderful introduction and the sharing of my childhood photos. Thank you all for being here at our second annual meeting of the Pediatric Trauma Society and making it such a wonderful meeting. As the title of my address suggests, none of us accomplish things completely alone, and the opportunity to serve as your president this past year is no exception. Although I have been fortunate to have a strong list of mentors throughout my life, training, and surgical career, I will highlight here those who have been my Pediatric Trauma Society partners and mentors. Four key mentors have been the presidents who came before me and the one who is about to follow me (Fig. 1). First, David Mooney, MD; without David’s vision, none of us would be sitting here at a national multidisciplinary pediatric trauma meeting. I, like several others in this room, was fortunate to be part of some early discussions with David at an Eastern Association for the Surgery of Trauma meeting. The concept of having a ‘‘home’’ for those of us who care for injured kids and share a desire to continually improve what we can do to keep kids safe, get them well after an injury, and get them back to their full potential, was much needed and inspirational. As our first president, he set the foundation and has been a friend and mentor to me as we all have moved the organization forward. Next is Lynn Haas, RN, MSN; I am fortunate that Lynn has been my trauma program manager as well as our organization’s second president. Lynn has taught me more than she knows about how to run a trauma program, and I know she has shared similar knowledge selflessly with many in this room and beyond. As our second president, Lynn had the unenviable task of leading the creation of our bylaws, a critical job and one that she was much better suited to accomplish than any of the surgeon leaders to date. Our third president was Barbara Gaines, MD; Barb led us through our first national meeting, a huge step in establishing our foothold as a true national organization. During her time, we became recognized as a national trauma organization by the American College of Surgeons’ Committee on Trauma and began our partnership with The Journal of Trauma and Acute Care Surgery. I have learned a lot from Barb’s leadership and friendship. Finally, our incoming President Robert Letton, MD; Bob has become a good friend and mentor during that last several years, and I am confident that our organization is in great hands and will continue its amazing growth under his leadership. Anyone who has ever been fortunate enough to lead an organization, big or small, will surely tell you, as a leader, you are only as good as those board members, committee chairs, and committee members who do the real work of the organization. I am certainly no different and will take just a moment to recognize our executive board members and committee chairs (Fig. 2). Our board, Bill Millikan, MD, secretary; Lisa Gray, RN, MSN, member at large; Terri Elsebernd, RN, MSN, member at large; Bob Letton, MD, president-elect; and our three departing board members, Laura Cassidy, PhD, member at large; Pina Violano, RN, MSN, treasurer; and Barb Gaines, MD, past president. Our committees did some amazing work this year and were led by the following committee chairs: Margot Daugherty, RN, MEd, program chair; Kathy Haley, RN, MSN, membership chair; Leann Wurster, RN, and Garret Free, EMT, marketing and technology chairs; John Petty, MD, guideline chair; Diane Hochstuhl, RN, MSN, education chair; and Matt Borgman, MD, and Rita Burke, PhD, research chairs. Finally, I certainly would not be here without my family. My grandparents, parents, and stepparents, mother-in-law, siblings, and of course, my wife Kelly and our three amazing children Chase, Calista, and Halle, your support and love are what motivates me. Now, on to the title of my talk, ‘‘Alone we can do so little, together we can do so much.’’ This Helen Keller quote seemed perfectly fitting to what I believe describes the future of the Pediatric
From the Comprehensive Children’s Injury Center, Division of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. This address was presented at the 2nd annual meeting of the Pediatric Trauma Society, November 6Y7, 2015, in Scottsdale, Arizona. Address for reprints: Richard A. Falcone, Jr., MD, MPH, Division of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229; email: [email protected]. DOI: 10.1097/TA.0000000000000965
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J Trauma Acute Care Surg Volume 80, Number 5
PTS 2015 Presidential Address
Figure 1. Presidents of the Pediatric Trauma Society. A, David Mooney, MD, MPH. B, Lynn Haas, RN, MSN. C, Barbara Gaines, MD. D, Robert Letton, MD.
Trauma Society. Despite Helen Keller’s multiple handicaps, she was able to achieve more than anyone thought possible and became an advocate for handicapped individuals everywhere. Although she was an incredibly motivated and strong woman, she realized she never could have achieved what she did without working together with others. I know there are a lot of amazing individuals in this room who work hard every day to improve the outcomes for injured children, but more importantly, I believe that by coming together and working together we can accomplish amazing things, moving forward for injured children and their families. When most people think about teamwork, their first thought goes to successful sports team. For me and in my home, those that come to mind are the New York Yankees, the New York Giants, and the Cincinnati Reds and Cincinnati Bengals; fortunately, the New York and Cincinnati teams that we cheer for are not in the same divisions and do not play head to head often! This view of teamwork inspires thoughts of athletes working together to play as a unit and win championships. According to Wikipedia (accessed November 2015), in health care, teamwork is a dynamic process involving two or more health care professionals with complementary background and skills, sharing common health goals and exercising concerted physical and mental effort in assessing, planning, or evaluating patient care. This explains what we do during a trauma resuscitation every day. There is perhaps no place like the trauma
resuscitation bay when a severely injured child arrives, who requires a group of people to come together with varied backgrounds and skills to work as a team to ensure the highest level of safe and high-quality care. Realizing the crucial role that teamwork and team communication play in caring for an injured child, especially during the acute resuscitation, 10 years ago, we began our multidisciplinary pediatric trauma simulation program. The goal of our program was to train as a team using high-fidelity simulators to improve our ability to communicate with each other, appreciate each other’s contribution to care, work better together to identify problems, and most importantly, improve safety and quality of care provided to injured children. Through this training, we have been able to demonstrate improvements in completion of key tasks, identify latent safety threats before reaching a patient, and continually train, evaluate, and improve our team function.1Y4 There are many others in this organization who have used simulation to learn and improve our trauma teamwork/performance during a resuscitation, and working together, we can move even further and beyond the doors of our trauma centers.5,6 Another key concept to allow the Pediatric Trauma Society to move care and outcomes for injured children forward is collaboration. A useful definition of collaboration is that it is the act of working with someone to produce or create something. Think of your favorite musical group, perhaps, the Beatles or the Dave Matthews band. Both groups are made up
Figure 2. Executive board. A, William Millikan, MD, secretary. B, Lisa Gray, RN, MSN, member at large. C, Terri Elsebernd, RN, MSN, member at large. D, Laura Cassidy, PhD, member at large. E, Pina Violano, RN, MSN, treasurer. 686
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PTS 2015 Presidential Address
of extremely talented individuals, but when they collaborate to make music, they create something better than any one of them could do on their own. The business world has been far ahead of health care in truly appreciating the value of collaboration. There have been countless books written on the topic of collaboration in business, and a recent review of several of these was recently published in the Harvard Business Review, ‘‘Collaborate for Real’’ (September 2015). In this article, they state that any business works better when its employees, teams, divisions, and leaders share ideas and resources to pursue a common goal. One example of failed collaboration they provide is one many of us of a certain age can certainly relate to. Many of us likely had our cherished Sony Walkman and our collection of cassette tapes. In the 1980s, the Sony Walkman dominated the market, but what happened to the Walkman that now leads my children to look at me with a quizzical look when I mention it? In the book The Silo Effect,7 the author describes how Sony missed the digital music revolution because its competing divisions could not agree on products, platforms, or strategy. As a consequence, the Sony Walkman is now a memory, and most of us carry around our music on our Apple or Android product carrying more music than our cassette-carrying case ever could have held. For the sake of the thousands of pediatric trauma patients who are cared for, we need to collaborate better. Although many of us in this room do work hard to break out of our silos, trauma care remains too siloed. There is the prehospital, emergency medicine, surgery (general/orthopedic/ neurosurgical), critical care, rehabilitation, and research silos. There is also a silo that crosses all of these but still at times is its own silo, patient services and social services. Fortunately, each of these silos is represented in the membership of the Pediatric Trauma Society, and I have been excited to see that so much communication across these silos is occurring at this meeting. Again learning from the business world, here are some keys to successful collaboration that we need to keep in mind. First, keep organizational boundaries flexible and fluid. Next, use technology to disrupt boundaries when they do exist. Third, share data, and let different interpretations be heard. Fourth, and in my opinion the most important, build trust by showing warmth and competence, appreciating others’ perspectives and revealing vulnerability. As I reflect on the last 4 years of our young organization and the last day and a half of this meeting, I am excited to say that I see each of these keys being exemplified. So how does collaboration in health care work beyond an organization’s annual meeting? When I attended the Harvard School of Public Health after completing my pediatric surgical fellowship, I had the opportunity to hear the ideas of Michael Porter for redefining health care. Michael Porter is well-known in the business world, but before him and his coauthor Elizabeth Olmstead Teisberg wrote Redefining Health Care,8 they were unknowns in the world of health care. In this book, they challenge the traditional specialty-based silo approach to health care. They argue that patients do not particularly care which subspecialist they see for their cardiac disease, inflammatory bowel disease, or any other ailment; patients want their problem cared for seamlessly, safely, and of high quality. They provide an argument and some examples from the Cleveland Clinic of how by working across silos, with a focus on a disease entity, outcomes could be improved, safety increased, and costs decreased. Imagine
the advances that could occur in trauma care if we did not have our ‘‘home’’ silos. In the research world, the Pediatric Emergency Care and Research Network (PECARN) is an example of a successful collaboration across numerous emergency departments. First funded by the Emergency Medical Services for Children in 2001, PECARN now has 18 hospital emergency department affiliates, 6 EMS affiliates, with 6 research nodes, an EMS node, and a data coordinating center. As a result of this collaborative network, more than 86 peer-reviewed multicenter articles have been published. Much of the funded work of PECARN has focused on the evaluation of pediatric trauma patients and influence the way we care for injured children.9Y13 When looking to improve patient safety, the Children’s Hospitals’ Solutions for Patient Safety is a leading collaborative example. This collaborative, now composed of more than 80 children’s hospitals, has shared goals of harm reduction including a 40% reduction in hospital-acquired conditions, 10% reduction in readmissions, and a 25% reduction in serious safety events. Since 2012, it is estimated that through the collaborative work, 4,746 children have been spared of serious harm with an estimated savings of $92 million (www.solutionsforpatientsafety.org). When looking at trauma in particular, an important collaborative to improve trauma care has been the American College of Surgeons’ Trauma Quality Improvement Program (TQIP) and the more recent Pediatric TQIP. The goal of TQIP is to elevate the quality of care for trauma patients by using risk-adjusted benchmarking, providing education on how to improve data quality, and how to accurately interpret your data and by providing opportunities to network and share information about best practices. At Cincinnati Children’s, we have developed a collaborative we call the Pediatric Trauma Transformation Collaborative (PTTC). The PTTC was initially developed in 2008 when at the suggestion of Dr. David Tuggle, a pediatric surgeon and American College of Surgeons site reviewer, the leadership of St. Mary’s Medical Center in Evansville, Indiana, came to meet with the trauma program leadership at Cincinnati Children’s to see how the two hospital might partner to improve pediatric trauma care. St. Mary’s had been a Level II adult trauma center with added qualifications in pediatrics, but when this verification status disappeared in 2006, they could not meet verification requirements as a Level II pediatric trauma center. Out of these initial meetings and the appreciation that more than 17 million children do not have access to pediatric trauma centers, we sought to develop a program to support hospitals committed to improving the care of injured children in their regions. The goal was to help provide a high quality of care in regions of need and to reduce the need to transfer injured children away from their families and support systems. The collaborative program includes the participation in monthly trauma performance improvement meetings by a pediatric surgeon from our experienced Level I pediatric trauma center, pediatric trauma guideline development and support, provision of pediatric trauma focused Continuing Medical Education/Continuing Education Unit opportunities, pediatric trauma multidisciplinary simulation training, and peer-to-peer support among physicians, nurses, program managers, registrars, and others as needed. Since its inception, we have now also partnered with Parkview Regional
* 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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J Trauma Acute Care Surg Volume 80, Number 5
PTS 2015 Presidential Address
Medical Center in Fort Wayne, Indiana, and Sanford Health in Fargo, North Dakota. As a result of the collaboration, all three sites are now verified American College of Surgeons Level II pediatric trauma centers; they have had increased patient volumes and decreased transfer rates; and they have expanded their portfolios of performance improvement initiatives and have demonstrated reductions in imaging and length of stay of children with solid organ injuries.14 Finally, at our institution, we realized that there was an incredible amount of talented individuals working on pediatric injury prevention and care but we were not very well aligned and were living in silos most of the time. As a result, we began what is now the Cincinnati Children’s Comprehensive Children’s Injury Center (CCIC). This has served to bring together the silos of injury prevention work in our emergency medicine division and trauma surgery as well as bring together diverse multidisciplinary providers to develop a multidisciplinary head injury clinic and develop cross-divisional research projects. I am incredibly proud of the 12 articles we have at this meeting, not simply because of the number but also because nearly all of them represent collaborative efforts across traditional silos. At this same meeting last year, we shared how our collaborative injury prevention approach, along with community partnerships, resulted in the development and implementation of a volunteer-driven home safety bundle that has resulted in population-based injury reductions for children younger than 5 years in our community. Before the collaborative work, we each had small and sometimes fleeting impact on the injury problem in our community. Another collaborative and community partnership injury prevention program that many of you have been involved in is our Buckle Up for Life program (www.buckleupforlife.org). This program works through a partnership of children’s hospitals with community organizations to increase child restraint use among high-risk populations. During the past 10 years, the program has been implemented through 13 hospitals and 167 community organizations across the country. At the sites where the program has been implemented, the rate of children unrestrained in cars decreased from 1 in 4 to less than 1 in 10; the rate of children in car seats increased from only 1 in 3 to 1 in 2; and although not a focus of the program, there was a 15% increase in the use of seat belts by adults as well. This brings me back to this organization and the thought of what we can do together. In just four short years, we have grown to more than 550 members, including 15 international members and including nurses, researchers, program managers, prehospital providers, surgeons from several disciplines, emergency medicine physicians, child abuse experts, rehabilitation specialists, as well as students and residents. We are here at only our second annual meeting with nearly 300 people registered and more than 60 wonderful articles. We have maintained a strong partnership with the Eastern Association for the Surgery of Trauma, a key organization that helped foster our early development. We now have a quarterly member newsletter, are active in guideline development and sharing, provide our members with access to online educational opportunities, have developing research partnerships, and have obvious networking across traditional silos as evidence at this meeting alone. 688
So how do we now go from good to great? The Pediatric Trauma Society needs to be the voice of the injured child worldwide. We need to be the forum where the best in pediatric trauma research is shared and nurtured. The Pediatric Trauma Society needs to be the organization that defines the direction of pediatric trauma related policy. The Pediatric Trauma Society needs to become the leading organization for pediatric traumarelated education. This needs to be through our annual meeting, through a robust online education platform, and by supporting the pediatric trauma education among our adult trauma organizations. I am confident that we will get there by continuing to appreciate the value in our intellectual diversity and supporting the excitement and energy of the new ideas we share. Thank you for the privilege of having served as your president, and continue to ask yourselves, ‘‘What can we make possible together?’’ REFERENCES 1. Falcone R, Daugherty M, Schweer L, Patterson M, Brown R, Garcia V. Multidisciplinary pediatric trauma team training using high fidelity trauma simulation. J Pediatr Surg. 2008;43(6):1065Y1071. 2. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2013;22:468Y477. 3. Patterson MD, Geis GL, LeMaster T, Wears RL. Impact of multidisciplinary simulation-based training on patient safety in a paediatric emergency department. BMJ Qual Saf. 2013;22:383Y393. 4. Couto TB, Kerrey BT, Taylor RG, FitzGerald M, Geis GL. Teamwork skills in actual, in situ, and in-center pediatric emergencies: performance levels across settings and perceptions of comparative educational impact. Simul Healthc. 2015;10:76Y84. 5. Parsons SE, Carter EA, Waterhouse LJ, Fritzeen J, Kelleher DC, O’Connell KJ, Sarcevic A, Baker KM, Nelson E, Werner NE, et al. Improving ATLS performance in simulated pediatric trauma resuscitation using a checklist. Ann Surg. 2014;259:807Y813. 6. Weinberg ER, Auerbach MA, Shah NB. The use of simulation for pediatric training and assessment. Curr Opin Pediatr. 2009;21:282Y287. 7. Tett G. The Silo Effect: The Peril of Expertise and the Promise of Breaking Down Barriers HardcoverVSeptember 1, 2015. New York, NY: Simon and Schuster; 2015. 8. Porter M, Olmsted Teisberg E. Redefining Health Care: Creating ValueBased Competition on Results. Boston, MA: HBR Press; 2006. 9. Garnett J, Harwayne-Gidansky I, Ward M, Critelli K, McLaren S, Ching K. 215: the PECARN head trauma rule: validating a clinical decision tool. Crit Care Med. 2015;43:55. 10. Faris G, Byczkowski T, Ho M, Babcock L. Prediction of persistent postconcussion symptoms in youth using a neuroimaging decision rule. Acad Pediatr. 2015. [Epub ahead of print]. 11. Mahajan P, Kuppermann N, Tunik M, Yen K, Atabaki SM, Lee LK, Ellison AM, Bonsu BK, Olsen CS, Cook L, et al. Comparison of clinician suspicion versus a clinical prediction rule in identifying children at risk for intra-abdominal injuries after blunt torso trauma. Acad Emerg Med. 2015;22:1034Y1041. 12. Holmes JF, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P, Adelgais K, Ellison AM, Yen K, Atabaki S, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;62:107Y116.e102. 13. Nigrovic LE, Lee LK, Hoyle J, Stanley RM, Gorelick MH, Miskin M, Atabaki SM, Dayan PS, Holmes JF, Kuppermann N, et al. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Arch Pediatr Adolesc Med. 2012;166:356Y361. 14. Falcone R, Milliken W, Bensard D, Haas L, Daugherty M, Gray L, Tuggle D, Garcia V. A paradigm for achieving successful pediatric trauma verification in the absence of pediatric surgical specialists while ensuring quality of care. J Trauma Acute Care Surg. 2016;80:433Y439.
* 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
