The Value Of In-House Call – Revisited Again

The value of in-house call for trauma surgeons has been contested for over a decade. Metrics for attending surgeon presence for trauma activations first appeared in the 2006 Optimal Resource document from the American College of Surgeons (Green Book). It called for the surgeon to ideally be present upon patient arrival, and no later than 15 minutes afterwards. This necessitated many trauma centers to mandate that the surgeons take in-house call so they could meet this standard.

As you might imagine, many were not happy about this. At Level I centers, the surgeons wanted to be able to rely on residents to help meet this requirement. The ACS was not too keen on letting them. So of course, people started doing research on the topic to prove their point of view.

I’m going to start off with an early paper on the topic from 2013. It was a rather sad initial attempt to show that surgeon presence didn’t make a difference. I’ll re-review that paper today, then move on to a more interesting one in my next post.

Of note: if you read just the abstract of this paper, you may come to the wrong conclusion! This is a perfect example of why you can’t just rely on the title or the abstract. Sometimes they cover up major flaws in the study.

This retrospective study primarily  of changes in patient mortality, as well as a few other length of stay (LOS) indicators  as the center changed over from having trauma surgeons who took call from home to taking in-house call. It involves only one trauma center in Lexington, Kentucky and covers two 21 month periods.

Here are the factoids:

  • There were roughly 5000 patients each in the at-home and in-house groups
  • Overall demographics looked identical, even though the authors thought they detected differences in age and ISS
  • Time in ED, ICU LOS, hospital LOS decreased significantly, and percent taken to OR increased in the in-house group. There was no change in mortality.
  • These patterns were the same in trauma activation patients, who were obviously more seriously injured.
  • The authors conclude that having an in-house surgeon does not impact survival, but can speed things up for patients throughout their hospital stay.

I have many problems with this study:

  • The statistical results are weird. Many of the allegedly significant differences appear to be identical (e.g. mean age 44+/-19 vs 45+/-19, hospital LOS 3 days vs 3 days). And even if the authors found a test that makes them look statistically significant, they are clinically insignificant. ICU LOS differences were measured in hours, and 25 hours was significant?
  • Attending presence “improved” from 51% to 88%. This means that they were not present in 1 of 5 trauma activations. This can easily overshadow any positive effect their presence may have had.
  • Mortality is too crude an indicator to judge the value of surgeon presence.
  • Lengths of stay can be due to so many other factors, it is not a valid measure either.
  • A retrospective, registry study has too few of the really critical data points

Bottom line: This paper is the poster child for why you MUST read the full paper, not just the abstract. If you had done the latter, you may believe that having an in-house surgeon is not necessary. Many papers prior to 2013 (of variable quality) have looked at this (poorly) and there is no consensus yet. But in-house call is a requirement for ACS verification if the surgeon can’t make it to the bedside of a seriously injured patients within 15 minutes. 

After observing trauma activations for 40 years, I know there is value in having an experienced surgeon present at the bedside during them. However, this value is very hard to quantify and every paper that has tried thus far has not looked at the right variables. And these variables cannot be assessed in a retrospective, registry type study. 

In my next post, I’ll look at a recent and better paper on the topic.

Reference: Influence of In-House Attending Presence on Trauma Outcomes and Hospital Efficiency. J Am College Surg 281(4):734-738, 2013.

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