Nearly universally, trauma surgeons at Level I and Level II trauma centers must be at the bedside within 15 minutes of the patient’s arrival. For most, this means that they must take in-house call. This requirement has been on the books for decades. It’s just the way we do it. And that makes it fair game to examine whether it is worth the extra work.

An older prospective comparison of two Level I centers (1990) reported no difference in care timing or clinical outcomes when surgeons taking call from home lived within 15 minutes of the hospital, received reliable paging activation, and responded promptly (reference 1). Unfortunately, these days, most surgeons cannot get to the hospital within 15 minutes at night unless they arrive in their pajamas.

A large 2003 retrospective study found no difference in mortality, time to OR, CT timing, or length of stay. However, this study depended on the presence of senior surgical residents in-house to provide initial care for the trauma patient until the attending surgeon arrived (reference 2).

The best study we have so far comes from a systematic review and meta-analysis by a trauma group in the Netherlands. It included 16 observational studies in the systematic review and 8 studies in the meta-analysis, involving nearly 65,000 trauma patients (reference 3). All papers compared patients treated by in-house surgeons with those treated by surgeons on call off campus. They only looked at the impact of the coverage model on mortality.

Here are the factoids:

• The meta-analysis showed a statistically significant risk-reduction of 14% in the patients managed by an in-house surgeon
• There was a further mortality reduction noted in more recent papers, with an overall reduction of 17%
• When five of the 16 papers identified as having severe bias were removed, the mortality decreased even further by a total of 19%
• Mortality was reduced at low-volume centers with in-house surgeons by 15%

Bottom line: I have been taking in-house trauma call for 40 years. It was interesting and exciting at first, but began to wear on me over time. My impression was that in 95% of the patients that I treated, the survival die was already cast. They were destined to live or die, and little that I could do would change that. However, that remaining 5% included the patients that I would look at afterward and think to myself, “If I hadn’t been here, we would have lost them.” 

This review article bears this out, but it only addresses mortality rates. I’m fairly certain that several other, more subtle processes are also improved. For now, trauma patients who need the highest level of care clearly benefit from having a trauma surgeon at their side upon arrival. Is taking call in-house the answer? If arriving at the bedside within the 15-minute limit can be accomplished from home with a short drive time (and sleeping in scrubs), the results should be the same. The key is having the surgeon present and ready to control life-threatening hemorrhage within minutes of their arrival. However, in most urban and suburban centers, the only way to guarantee this is to stay in the hospital.

References:

1. In-house versus on-call attending trauma surgeons at comparable level I trauma centers: a prospective study. J Trauma. 1999 Apr;46(4):535-40; discussion 540-2. doi: 10.1097/00005373-199904000-00001. PMID: 10217215.
2. The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients. J Trauma. 2003 Jul;55(1):20-5. doi: 10.1097/01.TA.0000071621.39088.7B. PMID: 12855876.
3. In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2021 Aug 1;91(2):435-444. doi: 10.1097/TA.0000000000003226. PMID: 33852558.