Severely injured patients benefit from in-house attending trauma surgeons

doi:10.1016/j.injury.2018.08.006

Injury

Volume 50, Issue 1, January 2019, Pages 20-26

https://doi.org/10.1016/j.injury.2018.08.006 Get rights and content

Abstract

Introduction

There is continuous drive to optimize healthcare for the most severely injured patients. Although still under debate, a possible measure is to provide 24/7 in-house (IH) coverage by trauma surgeons. The aim of this study was to compare process-related outcomes for severely injured patients before and after transition of attendance policy from an out-of-hospital (OH) on-call attending trauma surgeon to an in-house attending trauma surgeon.

Methods

Retrospective before-and-after study using prospectively gathered data in a Level 1 Trauma Center in the Netherlands. All trauma patients with an Injury Severity Score (ISS) >24 presenting to the emergency department for trauma before (2011–2012) and after (2014–2016) introduction of IH attendings were included. Primary outcome measures were the process-related outcomes Emergency Department length of stay (ED-LOS) and time to first intervention.

Results

After implementation of IH trauma surgeons, ED-LOS decreased (p = 0.009). Time from the ED to the intensive care unit (ICU) for patients directly transferred to the ICU was significantly shorter with more than doubling of the percentage of patients that reached the ICU within an hour. The percentage of patients undergoing emergency surgery within 30 min nearly doubled as well, with a larger amount of patients undergoing CT imaging before emergency surgery.

Conclusions

Introduction of a 24/7 in-house attending trauma surgeon led to improved process-related outcomes for the most severely injured patients. There is clear benefit of continuous presence of physicians with sufficient experience in trauma care in hospitals treating large numbers of severely injured patients.

Introduction

Improved outcomes for severely injured patients treated at designated trauma centers within an inclusive trauma system are well established [[1], [2], [3]]. One of the cornerstones of designated trauma centers has been timely involvement of trauma surgeons in the management of severely injured patients. With ongoing centralization of patients and further differentiation of hospitals, the question arises if trauma surgeons should be in house at all times in centers treating severely injured patients. However, there is ongoing debate regarding the value of such an in-house (IH) attending trauma surgeon [[4], [5], [6]].

In several Level 1 Trauma Centers, an IH attending trauma surgeon is available 24/7, whereas other institutions maintain an out-of-hospital (OH) on-call attending schedule with a reasonable response time [7,8]. In practice, OH on-call attending schedule means that a (senior) resident may serve as an in-house surgeon, while the attending surgeon participates in all major therapeutic decision-making and attends surgical procedures when needed.

Several studies have examined the effects of IH attending surgeons on process- and patient-related outcomes. On one side, there are studies that provide arguments that an IH attending improves efficiency of processes, such as faster decision-making, fewer errors, decrease of time to disposition and reduction in preventable deaths [6,[9], [10], [11]]. On the other side, there is no true consensus on the added value of 24/7 presence of an attending trauma surgeon in terms of overall mortality or hospital length of stay [12,13]. These latter outcomes are subject to the efficiency of the complete trauma care chain. Thus, when attempting to optimize the resuscitation process by introducing IH trauma surgeons, focus should be on process-related outcomes for this specific part of the chain. As stated by Durham et al, aggregate statistics and the use of surrogate markers to determine outcomes may not accurately portray the impact of attending surgeons on the quality of care [6].

Recently, an IH attending schedule with two experienced trauma surgeons available 24/7 has been introduced in our hospital. The aim of the present study was to compare process-relatedoutcomes before and after the introduction of an institutional IH attending trauma surgeon schedule in a single large volume Level 1 Trauma Center in the Netherlands.

Section snippets

Methods

The University Medical Center of Utrecht is a Joint Commission International (JCI) accredited tertiary care facility with 1000 beds. Our hospital complies with all requirements as defined by the American College of Surgeons’ Committee on Trauma (ACS-COT) for a Level 1 Trauma Center with the CT scan located nearby the Emergency Department (ED), thus not in the resuscitation bay [7]. Trauma team composition and tasks in our institution are described in detail by Kreb et al [14]. In July 2013, a

Population

A total of 7780 patients presented for 7935 unique traumas during the study period. An overview of the patients presenting and their dispositions are shown in Fig. 1. In supplementary Table 1, triage characteristics for all patients admitted for trauma are provided. Emergency Department length of stay (ED-LOS) and time to CT scan for the entire cohort are depicted in supplementary materials 2 and 3.

The population of patients presenting with ISS > 24 consisted of 606 patients presenting for 606

Discussion

After introduction of an in-house (IH) attending trauma surgeon schedule at our institution, there was significant acceleration of care-processes for severely injured patients, with a significant decrease in emergency department length of stay, a doubling in the percentage of patients that reached the ICU within an hour and a doubling in percentage of patients that arrived at the OR within 30 min.

At our institution, improving care for the most severely injured patients has always been of high

Conclusions

In conclusion, introduction of a 24/7 in-house attending trauma surgeon in a large volume Level 1 Trauma Center led to improved process-related outcomes, especially for the most severely injured patients. There is a clear benefit of the continuous presence of physicians with sufficient experience in trauma care in hospitals treating a large number of severely injured patients.

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Severely injured patients benefit from in-house attending trauma surgeons

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Population

Discussion

Conclusions

J Am Coll Surg

Surgery

Br J Anaesth

Resuscitation

Resuscitation

A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems

J Trauma

A national evaluation of the effect of trauma-center care on mortality

N Engl J Med

The effect of trauma center designation and trauma volume on outcome in specific severe injuries

Ann Surg

Debate regarding the necessity and benefits of attending surgeon in-house call for the care of acutely injured patients

J Trauma

Trauma attending in the resuscitation room: does it affect outcome?

Am Surg

In-house trauma attendings: is there a difference?

Am J Surg

American College of Surgeons Committee on Trauma: resources for optimal care of the injured patient

Trauma faculty and trauma team activation: impact on trauma system function and patient outcome

J Trauma Inj Infect Crit Care