How to effectively gather information for the ACS Trauma PRQ
Completing the American College of Surgeons (ACS) Trauma Program Review Questionnaire (PRQ) can feel like preparing for a high-stakes dinner party where the guests are all seasoned trauma surgeons—and they will notice if the silverware is out of place. The PRQ is not just a bureaucratic hurdle; it is the backbone of your trauma center’s verification process, ensuring that your program meets the rigorous standards for quality, safety, and performance improvement (American College of Surgeons [ACS], 2022).
The good news? With the right approach, gathering the required data can be less like herding cats and more like conducting a well-rehearsed orchestra.
1. Know Your Script: Understanding the PRQ Requirements
Before you start collecting data, you need to know exactly what the ACS is asking for. The PRQ covers a wide range of domains, including:
Institutional structure (e.g., trauma team composition, call schedules)
Clinical care processes (e.g., time to CT scan, massive transfusion protocol activation)
Performance improvement and patient safety (PIPS) activities
Trauma registry data (e.g., patient demographics, injury severity scores, outcomes)
Think of the PRQ as a recipe: missing one ingredient—say, your trauma registry’s compliance rate—can ruin the whole dish (ACS, 2022).
2. Befriend Your Trauma Registrar
Your trauma registrar is not just a data entry wizard—they are the keeper of the kingdom. The trauma registry is the single most important source for PRQ data, and its accuracy depends on:
Complete case capture (no patient left behind)
Timely abstraction (data entered within the ACS-recommended timeframes)
Validation processes (regular audits to ensure accuracy)
As Chisholm (2023) notes, implementing a robust trauma data quality plan aligned with ACS Standard 6.1 ensures that the numbers you submit are not just plentiful, but trustworthy.
3. Cross-Check with Other Departments
The PRQ isn’t just about numbers—it’s also about proving that your trauma center’s policies and practices align with ACS standards and that these standards are consistently upheld. This means collaborating with key departments to gather not only their written protocols but also evidence of how those protocols are implemented and monitored.
Emergency Department leadership – Collect the department’s trauma activation criteria, triage protocols, and documentation policies. Confirm that these are reviewed regularly, updated in line with ACS guidelines, and reinforced through staff training and mock drills.
Radiology – Obtain imaging prioritization policies for trauma patients, including guidelines for rapid CT access. Verify that these policies are supported by staffing plans, equipment maintenance schedules, and periodic performance audits.
Blood bank – Gather the massive transfusion protocol (MTP) and related blood product handling procedures. Ensure there is documentation of regular MTP drills, quality control checks, and compliance reviews to maintain readiness.
Operating room staff – Request surgical readiness policies, including criteria for immediate OR availability for emergent trauma cases. Confirm that these are backed by staffing rosters, on-call agreements, and after-action reviews following urgent cases.
In short, you’re not just asking, “Do you have a policy?” You’re asking, “Can you prove it works, and can you show me the receipts?” As the ACS emphasizes, verification is as much about demonstrating a culture of continuous compliance as it is about having the right documents in a binder (ACS, 2022).
4. Use Technology to Your Advantage
Manual data gathering is so 1990s. Many trauma centers now use:
Electronic health record (EHR) queries to pull time stamps and clinical metrics
Business intelligence dashboards for real-time performance tracking
Automated registry reports that align with ACS data fields
As Trauma News (2023) points out, aligning your registry fields with the ACS standards from the start can save you from a last-minute scramble.
5. Validate, Validate, Validate
Submitting inaccurate data is like showing up to the verification visit with mismatched socks—it’s memorable, but for the wrong reasons. Conduct internal audits, compare registry data with source documents, and ensure that definitions match ACS standards (ACS, 2022).
6. Keep a “PRQ Binder” Year-Round
Instead of treating the PRQ as a once-every-three-years panic attack, maintain a living document or digital folder with:
Updated policies and protocols
Quarterly registry reports
Meeting minutes from PIPS committees
Evidence of corrective actions taken
By keeping this binder (physical or virtual) current, you transform the PRQ from a frantic scavenger hunt into a simple act of compiling what you’ve already been tracking. This approach also reinforces a culture of readiness—because in trauma care, readiness is everything.
Conclusion: From Chaos to Confidence
Gathering data for the ACS Trauma PRQ doesn’t have to be a caffeine-fueled nightmare. By understanding the requirements, leveraging your trauma registrar’s expertise, collaborating across departments, embracing technology, and validating relentlessly, you can transform the process into a smooth, almost elegant operation.
After all, the PRQ is not just about passing a verification—it’s about telling the story of your trauma center’s commitment to excellence.
Call to Action
If your trauma center’s PRQ prep still feels like a last-minute fire drill, it’s time to flip the script. Start building a year-round culture of documentation, policy validation, and cross-department collaboration—before the ACS reviewers are on your doorstep. Schedule a “PRQ readiness check” this month, involve every department, and make your trauma data as bulletproof as your patient care. Because when verification day comes, you don’t just want to pass—you want to impress.
Want help organizing your PRQ data, download the Trauma Tidbits and ACS Audits—ACS PRQ Upload Checklist.
References
American College of Surgeons. (2022). Resources for optimal care of the injured patient. American College of Surgeons. https://www.facs.org/quality-programs/trauma/quality/verification-review-and-consultation-program/process/
Chisholm, A. (2025). Implementing a trauma data quality plan using ACS Standard 6.1. OHA, LLC. https://oha-llc.com/implementing-a-trauma-data-quality-plan-using-acs-standard-6-1/
Trauma News. (2023, February 10). Everything about trauma registry in the new ACS trauma standards. Trauma News. https://trauma-news.com/2023/02/everything-about-trauma-registry-in-the-new-acs-trauma-standards/
