Category Archives: Trauma Center

Optimizing Feedback To Referring Hospitals

The American College of Surgeons requires that referring hospitals provide feedback to prehospital providers and referring hospitals regarding the transfer process.

Failure to do so can actually result in a weakness or deficiency during a site visit. (Psst! Pay attention, referring hospitals if you want to start getting feedback. Read that first sentence again.) Sometimes the feedback is verbal, either in person or by phone. Many receiving centers send written letters outlining care and care issues. But unfortunately, some don’t do it at all, or only very inconsistently.

Harborview Hospital in Seattle is a very busy Level I center, with nearly 6,000 trauma admissions per year. More than half of their patients come from a huge catchment area including Washington state, Wyoming, Alaska, Idaho, and Montana. The amount of work to provide proper feedback on over 3,000 patients annually can be overwhelming.

They implemented a “U-link” program that provided access to patient chart info for the hospital sending each patient. It was HIPAA compliant, and login information was sent within 72 hours of patient arrival.

Here are the factoids:

  • 90 referring hospitals set up the U-link system
  • Care transcripts, radiology reports, and discharge summaries were the most frequently viewed items
  • The most desired feedback was on over- or under-resuscitation (89%), injuries (84%), appropriateness of transfer (78%), and deviation from ATLS protocols (76%)
  • Information was used for education (100%), systems analysis (99%), and performance improvement (PI, 92%)

Bottom line: Your referral partners crave feedback on the patients they send! Develop a system that guarantees it on each patient at a reasonable time after admission. You may or may not be able to link them into your specific electronic medical record, but you can certainly send out informational letters and email!

Reference: Optimizing feedback from a designated Level I trauma/burn center to referring hospitals. JACS 220(1):99-104, 2015.

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The Value Of In-House Call – Part 2

In my last post, I detailed an older study that did not show much of an impact from having the trauma surgeon in-house at all times. However, like many of the papers published on this over the years, it suffered from small numbers and questionable endpoints.

A group in the Netherlands sought to analyze everything they could find on the topic and perform a meta-analysis and systematic review. They scanned the literature beginning in 1976, the year that the ACS Committee on Trauma published the first resource criteria for trauma center verification. A total of 16 studies (RCTs and observational) that included information on over 64,000 patients were carefully selected for study. The endpoints of interest were in-hospital mortality and several process measures including lengths of stay and time to OR and CT.

Here are the factoids:

  • In-house mortality significantly decreased with in-house surgeons, with a relative risk reduction of 14% (from good quality papers, primarily published after 2000)
  • ICU length of stay was shorter with an in-house surgeon in four studies, longer in one
  • Hospital length of stay was shorter with the in-house surgeon in four studies, longer in two
  • Time to OR was significantly faster in seven studies with an in-house surgeon, but no difference was seen in five
  • Time to CT was shorter in one study and no different in four with the in-house surgeon

Bottom line: What does it all mean? We have been led to believe that doing a meta-analysis / systematic review can help us make sense of a group of papers with flaws such as low numbers, questionable design, or bias. This work shows that this is not necessarily the case.

Think of a  good meta-analysis as a set of eyeglasses focused on a selected body of literature. The blurry individual papers are grouped together and brought into better focus by the meta-analysis process. However, the final visual acuity is still determined by the overall quality of the individual research works.

If the overall quality is low, things will remain somewhat blurry even after meta-analysis. As individual paper quality improves, or the papers at least include some higher quality data mixed in with chaff, the overall clarity of the meta-analysis gets better and better.

In this meta-analysis, all papers included mortality information. There is enough there to show the association of an in-house trauma surgeon and lower mortality. But as with all association studies, it is impossible to say that the improved survival is due to the surgeon alone. There are many other factors that were not or could not be evaluated in the studies that might parallel the presence of the surgeon. And similarly with the process measures (LOS, time to resource use), we are generally seeing a preponderance of that show a positive effect. But it’s still not open and shut. 

I interpret this meta-analysis / systematic review as overall positive and supportive of having an in-house surgeon. It definitely dovetails with my own experience with in-house call over the past 38 years. I recognize the crudeness of the outcome measures selected, and our inability to quantify more subtle benefits. And we still haven’t fully figured it out the value, even after over 20 years of decent studies. This means we probably won’t ever fully know the answer since the system we work in continues to shift, potentially rendering the older information obsolete.

We will most likely continue with in-house call at highest-level trauma centers for the foreseeable future. In my opinion, and as is suggested by most of the literature, that is a good thing for our patients.

Reference: In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis, Journal of Trauma and Acute Care Surgery: August 2021 – Volume 91 – Issue 2 – p 435-444,

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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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Best Of EAST #14: Trauma Center Access

The trauma group at MetroHealth in Cleveland has previously published a paper that examined the impact of Level I trauma centers in close proximity on their surrounding population. They have expanded this work to look at changes in the number of trauma centers of any level over a five year period and the populations that they serve across the US. The group was interested in elucidating the number of centers that opened in previously unserved areas, and the whether these areas were economically disadvantaged.

They used a list of state designated trauma centers maintained by the American Trauma Society. Level I and II centers were grouped together, as were Levels III through V. Census tracts around centers were categorized as “served” if the population surrounding it was within a 30 minute drive time of the center.

Here are the factoids:

  • The number of trauma centers increased by 256 to a total of 2140 in 2019, and 82% of these were Levels III-V
  • Nationwide coverage in terms of census tracts served increased from 75% to 80%
  • The increase in total population served was similar, rising from 76% to 79%
  • 91% of new Level I-II centers were in areas that were already served by other high level centers, and 86% of new Level III-V centers were in already served areas
  • New Level III-V centers were opened in areas with higher poverty than Level I-II centers (16% vs 13%)

The authors concluded that the numbers of trauma centers is increasing over time, but that more Level III-V centers are moving into underserved areas.

Bottom line: The authors have identified a novel way to suggest the financial motivations of opening trauma centers. When trauma systems were first implemented, there was an overall goal to provide coverage for the general population. But only a few states wrote guidelines that would attempt to evenly and equitably distribute new centers within and across counties.

The American College of Surgeons wrote a white paper and created a tool to assist in determining how many trauma centers were needed to serve a given population. Unfortunately, implementation of the tool was left to the states, and their legislatures had little interest in adding it to their system regulations after the fact.

So in some states, it’s like the wild, wild west with new centers opening almost next door to established and storied trauma hospitals. This abstract demonstrates that this phenomenon is real. But unfortunately, Pandora’s box was opened long ago and I don’t see that anything will change to address this situation in the foreseeable future.

Here are my questions for the authors and presenter:

  • Are the trends you identified general ones across the US, or are they focused in particular states?
  • Do you have any information on the impact of this trend on already existing trauma centers?
  • Can you speculate about what can be done to ameliorate this trend going forward?

This is a fascinating abstract about a non-clinical issue that has major implications for existing trauma programs (and especially certain states) well into the future.


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When Should You Activate Your Backup Trauma Surgeon?

The American College of Surgeons requires all US Trauma Centers to publish a call schedule that includes a backup trauma surgeon. This is important for several reasons:

  • It maintains a high level of care when the on-call surgeon is encumbered with multiple critical patients, or has other on-call responsibilities such as acute care surgery
  • It reduces the need to place the entire trauma center on divert due to surgeon issues

However, the ACS does not provide any guidance regarding the criteria for and logistics of mobilizing the backup surgeon. In my mind, the guiding principle is a simple one:

The backup should be called any time a patient is occupying the on-call surgeon’s time to the extent that they cannot manage the care of a newly arrived (or expected to arrive) patient with critical needs that only the surgeon can provide.

There’s a lot of meat in that sentence, so let’s go over it in detail. 

First, the on-call surgeon must already be busy. This means that they are actively managing one or more patients. Depending on the structure of the call system, they may be involved with trauma patients, general/acute care surgery patients, ICU patients, or a combination thereof. Busy means tied up to the point that they cannot meaningfully manage another patient.

Note that I did not say “evaluate another patient.” Frequently, it is possible to have a resident (at an appropriate training level) or advanced practice provider (APP) see the new patient while the surgeon is tied up, say in the operating room. They can report back, and the surgeon can then weigh his or her choices regarding the level of management that will be needed. Or if operating with a chief resident, it may be possible for the surgeon to briefly leave the OR to see the second patient or quickly check in on the trauma resuscitation. Remember, our emergency medicine colleagues can easily run a trauma activation and provide initial care for major trauma patients. They just can’t operate on them.

What if the surgeon is in the OR? Should they call the backup every time they are doing a case at night? Or every time a trauma activation is called while they are doing one? In my opinion, no. The chance of having a highest level trauma activation called is not that high, and as above, the surgeon, resident, or APP may be able to assess how much attention the new patient is likely to need. But recognize that the surgeon may not meet the 15 minute trauma activation attendance requirement set forth by the ACS.

However, once such a patient does arrive (or there is notification that one of these patients is on the way), call in the backup surgeon. These would include patients that are known to, or are highly suspected of needing immediate operative management. Good examples are penetrating injuries to the torso with hemodynamic problems, or those with known uncontrolled bleeding (e.g. mangled extremity).

If two or more patients are being managed by the surgeon, and they believe that they would not be able to manage another, it’s a good idea to notify the backup that they may be needed. This lets them plan their evening better to ensure rapid availability.

Finally, what is the expected time for the backup to respond and arrive at the hospital to help? There is no firm guideline, but remember, your partner and the patient are asking for your assistance! In my opinion, total time should be no more than 30 minutes. If it takes longer, then the trauma program should look at its backup structure and come up with a way to meet this time frame.

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