Category Archives: Trauma Center

Trauma Centers: The 30-Minute Rules for Orthopedic Surgery and Neurosurgery

I’m kicking of a week-long series for trauma program leaders that explains the details of a trauma center requirement that creates confusion for many. With the adoption of the 2014 Resources for Optimal Care of the Injured Patient (i.e. The Orange Book), a number of new requirements were introduced to obtain and maintain status as an American College of Surgeons verified trauma center. One (or actually two) of the requirements for Level I and II centers are known collectively as the 30-minute rules.

The 30-minute rules apply to both orthopedic surgeons and neurosurgeons. They state that care must be continuously available and that a service representative “must be present and respond within 30 minutes based on institutional-specific criteria.” And most who peruse the Orange Book have already realized, any phrase that contains the word must denotes that failure to meet the requirement will result in a deficiency during a site review, whereas the word shall means that it will likely result in a weakness.

For the rest of the week, I’ll work through these requirements. I will describe what they mean and what some typical institutional-specific criteria are. I will explain who is actually required to respond. I’ll work through the logistics of being able to accurately record their response time, and offer best practices for how to capture it. And finally, I’ll look at the consequences of not meeting these criteria.

Tomorrow: Typical criteria for orthopedic surgery and orthopedics.

 

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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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Best of AAST #3: Level I vs Level II Trauma Centers

There is an ongoing debate over the differences between Level I vs Level II trauma centers in the US. On paper, the major differences include resident rotations in trauma, research, and the available of certain specialty surgeons and services. There have been several papers that look at survival differences between the two levels.

One podium paper at AAST 2018 re-examines this debate. It is a medium-sized pooled series that looks at a particular type of injury, pelvic ring fractures. These injuries can be complex, and many times require specialized orthopedic expertise. ACS Level I centers are required to have at least one Orthopedic Trauma Association fellowship-trained surgeon among their orthopedists. This is not required for Level II centers, but many do have them.

The group at the University of Michigan examined patients with partially stable or unstable pelvic ring injuries in a trauma collaborative database including 29 Level I and Level II centers over a 7-year period. They used propensity matching to compare 610 patients admitted to Level I and 610 patients admitted to Level II centers with these injuries:

Here are the factoids:

  • Mortality was significantly increased at Level II centers ( 12%) vs Level I centers (8%)
  • Angiography was used significantly less at Level II centers (6% vs 11%)
  • Complex repairs were used significantly less frequently at Level II centers (32% vs 42%)
  • Patients were significantly less likely to be admitted to an ICU at Level II centers, and were more often admitted to stepdown units (45% vs 52%)
  • Failure to rescue rate was lower (better) in ICU patients

Bottom line: Obviously, there are some limitations to using this pooled data, but it does provide larger numbers than many similar papers have. It cannot distinguish Level II centers that have OTA-trained orthopedic surgeons from those that do not. But the results are rather striking. It’s not clear exactly which of the institutional differences might be responsible for the improved mortality, and they all probably contribute to some degree. But the abstract appears to show that Level II centers are not just non-academic Level Is. This work suggests that certain injury patterns really should be transferred to a center with the specialized resources to treat it well.

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Best of AAST #1: The Price of Being a Trauma Center

The annual meeting of the American Association for the Surgery of Trauma (AAST) begins in two weeks. Today, I will kick off a series of commentaries on many of the abstracts being presented at the meeting. All readers should be aware that I have only the abstracts to work with. As I always caution, final judgement cannot be passed until the full paper has been reviewed. And many of these will not make the jump to light speed and ever get published. So take them with a grain of salt. They may point to some promising developments, but then, maybe not.

First up is a nice analysis on the price of being a trauma center. One of my mentors, Bill Schwab, always used to say that trauma centers are always in a state of “high-tech waiting.” It costs money to keep surgeons in house, other medical and surgical specialists at the ready, and an array of services and equipment available at all hours. Any hospital administrator can tell you that trauma is expensive. But how expensive, exactly?

The trauma group at the Medical Center of Central Georgia in Macon did a detailed analysis of the cost of readiness for trauma centers in the year 2016. The Georgia State Trauma Commission, trauma medical directors, trauma program managers, and financial officers from the Level I and II centers in Georgia determined the various categories and reported their actual costs for each. An independent auditor reviewed the data to ensure reporting consistency. Significant variances were analyzed to ensure accurate information.

Here are the factoids:

  • Costs were lumped into four major categories:  administrative, clinical medical staff, in-house OR, and education/outreach
  • Clinical medical staff was the most expensive component, representing 55% of costs at Level I centers and 65% at Level II
  • Only about $110,000 was spent annually on outreach and education at both Level I and II centers, representing a relative lack of resources for this component.
  • Total cost of being a Level I center is about $10 million per year, and $5 million per year for Level II

Here is a copy of the table with the detailed breakdown of each component:

Bottom line: Yes, it’s expensive to be a trauma center. It’s a good idea for any trauma center wannabe to perform a detailed  analysis to make sure that it makes sense financially. This is most important in areas where there are plenty of trauma centers already.  Tools have been developed to determine how many trauma centers will fit within a given geographic area (see below). Unfortunately, very few if any states use this tool to determine how many centers are reasonable. In come cities, it’s almost like the wild west, with centers popping up at random all over the place. This abstract suggests that an additional analysis is mandatory before taking the plunge into this expensive business.

Related post:

Reference: How much green does it take to be orange? Determining cost associated with trauma center readiness. Podium abstract #18, session VIII, AAST 2018.

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Secondary Overtriage: What Is It, And Why Is It Bad?

Simply put, secondary overtriage (SO) is the unnecessary transfer of a patient to another hospital. How can you, as the referring trauma professional, know that it is unnecessary? Almost by definition, you can’t, unless you have some kind of precognition. If you knew it wasn’t necessary, you wouldn’t do it in the first place, right?

But using the retrospectoscope, it’s much easier. The classic definition describes a patient who is discharged from the hospital shortly after arrival there. What is “shortly?” Typically, it occurs within 48 hours in a patient with low injury severity (ISS < 16) and without operative intervention. Definitions may vary slightly.

And why is it bad?

Several states with rural trauma systems have scrutinized this issue. The first study is from West Virginia, where six years of state registry data were analyzed. Over 19,000 adults were discharged home from a non-Level I center within 48 hours after an injury. Of those, about 1,900 (10%) had been transferred to a “higher level of care” and discharged from that center (secondary overtriage, could be any higher-level trauma center).

The factoids:

  • Patients with ISS > 15 and requiring blood transfusion were more likely to be SO. (I would argue that this is appropriate triage in most cases!)
  • Neurosurgical, spine and facial injuries were also associated with SO. (This one is a little more interesting, see below).
  • SO was more likely for transfers during the night shift, when resources are often more scarce

The problem is that this study is descriptive only. It doesn’t really help us figure out which patients could/should be kept based on any of the variables they collected.

The next study is from Dartmouth in New Hampshire and examines transfers into that single Level I center from 72 other hospitals. Registry data were examined over 5 years, identifying transfer patients with ISS < 15 who were discharged within 48 hours without an operation.

Yet more factoids:

  • 62% of the nearly 8,000 patients received by this center were transfers
  • Overall SO rate was 26%
  • A quarter of adult patients and one half of pediatric patients were considered SO, and about 15% of them were actually discharged from the ED (!)
  • Head and neck, and soft tissue injuries were most common among SO patients

The real bottom line: Here are my thoughts on what you can do to try to decrease the number of your patients with SO and optimize the transfer process:

  • Work with your upstream trauma center to determine how much imaging you really need to perform
  • Develop a reliable method of getting those images to them
  • Ask them to help you develop practice guidelines and educate your hospital/ED staff to help manage common diagnoses that often result in SO from your center
  • If you are located in a rural area, inquire about RTTD courses you might attend

References:

  • Secondary overtriage in a statewide rural trauma system. J Surg Research 198:462-467, 2015.
  • Secondary overtriage: the burden of unnecessary interfacility transfers in a rural trauma system. JAMA Surg 48(8):763-768, 2013.
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