Trauma: the paradigm for medical care in the 21st century

The acute care surgery model and elective surgery

ABSTRACT

Two senior surgeons with active elective surgery practices call on their personal experiences to encourage acute care surgery programs to explore ways to incorporate elective surgery into their practice models. Although there are obstacles, these are not insurmountable problems, potential solutions exist, and this may help protect against burnout.

Impact of acute care surgery on timeliness of care and patient outcomes: a systematic review of the literature

Background

Dedicated emergency general surgery (EGS) service models were developed to improve efficiency of care and patient outcomes. The degree to which the EGS model delivers these benefits is debated. We performed a systematic review of the literature to identify whether the EGS service model is associated with greater efficiency and improved outcomes compared to the traditional model.

Methods

We searched MEDLINE, Embase, Scopus and Web of Science (Core Collection) databases from their earliest date of coverage through March 2017. Primary outcomes for efficiency of care were surgical response time, time to operation and total length of stay in hospital. The primary outcome for evaluating patient outcomes was total complication rate.

Results

The EGS service model generally improved efficiency of care and patient outcomes, but the outcome variables reported in the literature varied.

Conclusion

Development of standardized metrics and comprehensive EGS databases would support quality control and performance improvement in EGS systems.

Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status

IMPORTANCE

Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non–trauma center emergency departments (EDs).

OBJECTIVES

To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non–trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non–trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region.

MAIN OUTCOMES AND MEASURES

Inpatient admission vs transfer to another acute care facility.

RESULTS

In 2009, a total of 4513 observations from 636 non–trauma center EDs were available for analysis, representing a nationally weighted population of 19,312 non–trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non–trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non–teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10,000 annual ED visits).

CONCLUSIONS AND RELEVANCE

Patients with severe injuries initially evaluated at non–trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.

Motor vehicle collision fatalities involving alcohol and illicit drugs in Greece: the need for management protocols and a reassessment of surveillance

AIMS

The frequency and the effect of alcohol and illicit drugs on injury type, severity and location of death in motor vehicle collision (MVC) fatalities were investigated.

DESIGN

Retrospective case-control study based on autopsy and toxicology.

SETTINGS

Single faculty accepting referrals from Greater Athens and prefectures.

PARTICIPANTS

Consecutive pre-hospital and in hospital fatalities.

MEASUREMENTS

Demographics, toxicology, abbreviated injury scale (AIS), injury severity score (ISS), and location of death.

FINDINGS

Of the 1860 screened subjects, 612 (32.9%) constituted the positive toxicology group (PTG) for alcohol or illicit drugs or both and the 1248 (67.1%) the negative toxicology group (NTG). The median age was 34 (4-90) years for the PTG and 45 (3-97) years for the NTG. The PTG included significantly higher proportions of males and motorcyclists. The PTG had a 50% increased risk for a severe (AIS ≥3) cervical spine and 85% for a severe upper extremity injury, compared to the NTG. A total of 29.2% of the PTG and 22.4% of the NTG deaths were non-preventable (ISS=75). The frequency of severe trauma (ISS ≥16) was comparable between PTG and NTG (P=0.87). The PTG presented with a median ISS of 43 (6-75) versus 41 (2-75) of the NTG, hence without significant difference (P=0.11). The pre-hospital death rate was 77.8% for the PTG versus 58% of the NTG (P<0.001). The analysis confirmed that the odds of positive toxicology were considerably higher in the subjects who arrived dead at the hospital (OR 2.62, P <0.001).

CONCLUSIONS

In the greater Athens region, almost a third of motor vehicle collision-related fatalities involved alcohol, illicit drugs or both. Individuals screened positive for alcohol or drugs were 2.6 times more likely to die before hospital admission than those with a negative toxicology screen, despite comparable injury severity. Specific evidence-based management protocols and reassessment of surveillance are required.

Acute care surgery: a new training and practice model in the United States

The specialty of trauma is at a crossroads. Choosing a career in trauma is associated with concerns related to lifestyle issues and maintenance of adequate operative experience. Trauma and critical care surgeons in the U.S. have reexamined their role based on these concerns and the realization that surgeon resources for the injured patient are in jeopardy. After much work over the past five years, a model of "Acute Care Surgery" has emerged and a training curriculum has been proposed. This article reviews the evolution of a new specialty and identifies some of the challenges and opportunities associated with the implementation of this model.

The U.S. trauma surgeon's current scope of practice: can we deliver acute care surgery?

BACKGROUND

The evolving discipline of acute care surgery as an expansion of trauma surgery is undergoing intense critique. As we envision this new paradigm of surgical practice, an evaluation of our current status across the nation's trauma centers is an essential step. The purpose of this study is to determine the practice patterns of trauma surgeons at major trauma centers throughout the United States.

METHODS

A survey was sent to the trauma directors of the 1,288 designated trauma centers in the United States, as listed by the American Trauma Society. As proposed, acute care surgery would encompass performing emergent abdominal, vascular, and thoracic trauma procedures as well as providing critical care. The addition of simple orthopedic and neurosurgical procedures has been considered.

RESULTS

The survey response rate was 72% among the Level I/II/III centers (n = 515) with 92% of Level I, 72% of Level II, and 59% of Level III centers responding. Of the 169 Level I centers, 31 (18%) reported their trauma surgeons perform the full complement of thoracic, vascular, and abdominal cases. Trauma surgeons managed the full range of injuries at 11 (6%) of the 187 Level II centers and 7 (4%) of the 159 Level III centers. At these 49 centers, only 41% of surgeons perform elective thoracic and vascular cases. The remaining 466 centers enlist a combination of vascular and thoracic surgeons to manage trauma patients. Finally, trauma surgeons performed cranial burr holes at eight trauma centers, placement of ICP monitors at four, and open fracture washout at three trauma centers.

CONCLUSIONS

The model of the acute care surgeon is attractive and timely, but only a limited number of trauma surgeons currently practice this proposed range of operative procedures; even fewer surgeons have an elective surgical practice to maintain key operative skills. Fellowship training programs need to incorporate vascular and thoracic procedures to enable the specialty of acute care surgery.

Trauma surgery: discipline in crisis

Throughout the past quarter century, there have been slow but dramatic changes in the nature and practice of trauma surgery, and this field increasingly faces potent economic, logistic, political, and workforce challenges. Patients and emergency physicians have much to lose by this budding crisis in our partner discipline. This article reviews the specific issues confronting trauma surgery, their historical context, and the potential directions available to this discipline. Implications of these issues for emergency physicians and for trauma care overall are discussed.

Do the American College of Surgeons’ “Major Resuscitation” Trauma Triage Criteria Predict Emergency Operative Management?

STUDY OBJECTIVE

We wish to assess whether individual or collective American College of Surgeons' "major resuscitation" criteria accurately identify injured patients who receive emergency operative treatment.

METHODS

In this observational secondary registry analysis of 8,289 consecutive trauma team activations during a 7.5-year period, we evaluated the test performance of 5 American College of Surgeons' major criteria in predicting emergency (within 1 hour) operative management by general (for adults) or pediatric (for children) surgeons.

RESULTS

In adults, the individual major resuscitation criteria each predicted emergency operative management as follows (sorted from highest to lowest test performance): gunshot wounds to the neck or torso (likelihood ratio positive [LR+] 7.5; 95% confidence interval [CI] 6.2 to 9.1); confirmed hypotension (LR+ 5.3; 95% CI 4.0 to 7.1); interhospital transfers requiring blood transfusions (LR+ 4.6; 95% CI 2.6 to 8.2); respiratory compromise (LR+ 2.9; 95% CI 2.2 to 3.7), and Glasgow Coma Scale score less than 8 (LR+ 2.1; 95% CI 1.6 to 2.7). The collective strategy of using any of these 5 criteria exhibited a LR+ of 3.5 (95% CI 3.2 to 3.8), sensitivity 82% (95% CI 75% to 87%), and specificity 76% (95% CI 75% to 77%). Our findings in children were similar, but their precision was limited by the low baseline prevalence of emergency operative intervention.

CONCLUSION

These 5 American College of Surgeons-mandated major resuscitation criteria vary several-fold in their individual ability to predict emergency operative management and collectively exhibit modest test characteristics for this purpose. Selective use of these criteria or revisions thereof could result in more efficient secondary trauma triage. Our results do not support the existing obligatory use of these criteria to maintain American College of Surgeons trauma center certification.

Is There Evidence to Support the Need for Routine Surgeon Presence on Trauma Patient Arrival?

The trauma center certification requirements of the American College of Surgeons include the expectation that, whenever possible, general surgeons be routinely present at the emergency department arrival of seriously injured patients. The 2 historical factors that originally prompted this requirement, frequent exploratory laparotomies and emergency physicians without trauma training, no longer exist in most modern trauma centers. Research from multiple centers and in multiple varying formats has not identified improvement in patient-oriented outcomes from early surgeon involvement. Surgeons are not routinely present during the resuscitative phase of Canadian and European trauma care, with no demonstrated or perceived decrease in the quality of care. American trauma surgeons themselves do not consistently believe that their use in this capacity is either necessary or an efficient distribution of resources. There is not compelling evidence to support the assumption that trauma outcomes are improved by the routine presence of surgeons on patient arrival. Research is necessary to clarify which trauma patients require either emergency or urgent unique expertise of a general surgeon during the initial phase of trauma management. Individual trauma centers should be permitted the flexibility necessary to perform such research and to use such findings to refine and focus their secondary triage criteria.

Emergency revascularization in patients with cardiogenic shock on admission: a report from the SHOCK trial and registry

AIMS

To determine clinical correlates and optimal treatment strategy in patients with cardiogenic shock (CS) on admission.

METHODS AND RESULTS

In SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK? (SHOCK) trial and registry patients with left ventricular (LV) dysfunction (n=1053), CS on admission occurred in 26% of directly admitted patients (n=166/627). Time from myocardial infarction to CS was shorter, initial haemodynamic profile poorer, and aggressive treatment less frequent in CS on admission than in delayed CS patients. CS on admission patients constituted a smaller relative proportion (11%) of the transferred (n=48/426) when compared with the directly admitted cohort (P<0.001). In-hospital mortality was higher (75 vs. 56%; P<0.001) with more rapid death (24-h mortality 40 vs. 17%; P<0.001) in CS on admission than in delayed CS patients. Emergency revascularization reduced in-hospital mortality in CS on admission (60 vs. 82%; P=0.001) and in delayed CS patients similarly (46 vs. 62%; P<0.001; interaction P=0.25). After adjustment for clinical differences, CS on admission was an independent predictor of in-hospital mortality (P=0.008).

CONCLUSION

CS on admission patients have a worse outcome but benefit equally from emergency revascularization as delayed CS patients, emphasizing the need for rapid and direct access of CS on admission patients to facilities providing this care.

Clinical decision rules for secondary trauma triage: predictors of emergency operative management

STUDY OBJECTIVE

Most injured patients taken by ambulance to hospital emergency departments do not require emergency surgery, yet most US trauma centers require a surgeon to be present on their arrival. If a clinical decision rule could be developed to accurately identify which injured patients require emergency operative intervention, then such "secondary triage" criteria could permit a trauma center to more efficiently use their surgeons' time.

METHODS

We analyzed 7.5 years of data (8,289 consecutive trauma activations) in our prospectively maintained Level I trauma center registry. We used classification and regression tree analyses to generate clinical decision rules using standard out-of-hospital variables to identify emergency operative intervention (within 1 hour) by a general surgeon (for adults) or a pediatric surgeon (if < or =14 years).

RESULTS

Emergency operative intervention occurred in 3.0% of adults and 0.35% of children. For adults, summoning a surgeon for any one of 3 criteria (penetrating mechanism, systolic blood pressure <96 mm Hg, pulse rate >104 beats/min) could reduce surgeon calls by 51.2% while failing to identify emergency operative intervention in only 0.08% (rule sensitivity 97.2% and specificity 48.6%). For children, no rule at all (ie, never automatically summoning a surgeon) would fail to identify emergency operative intervention in only 0.35% of patients, and use of a single criterion (penetrating mechanism) would reduce surgeon calls by 96.2% while failing to identify emergency operative intervention in only 0.09% (rule sensitivity 75.0% and specificity 96.5%).

CONCLUSION

We have derived simple decision rules for trauma centers that, if validated, could substantially reduce the need for routine surgeon presence on trauma patient arrival. These rules demonstrate low false-negative rates.

Profitable versus unprofitable expansion of trauma and critical care surgery

BACKGROUND

The American Association for the Surgery of Trauma has proposed that the specialty of trauma and critical care include emergency surgery. We assessed whether this change will have an impact on the financial challenges that this specialty confronts, including inadequate reimbursement for efforts exerted.

METHODS

Over a 2-year period, we collected financial data on 6 trauma and critical care surgeons. Three included emergency surgery as part of their practice, but no private elective component. The other 3 included both emergency surgery and a private elective component.

RESULTS

Trauma and critical care surgeons who had included emergency surgery but no private elective component had significantly lower charges (5,941,482 US dollars vs 9,209,535 US dollars), collections (1,439,913 US dollars vs 2,973,319 US dollars), generated relative value units (50,440 vs 80,327), generated reimbursement per relative value units (28.55 US dollars vs 37.02 US dollars), and margins (0.20 US dollars vs 1.48 US dollars) than their counterparts who had an elective surgery component.

CONCLUSION

The addition of emergency surgery did not improve the financial viability of trauma and critical care as a specialty. Without significant hospital or governmental financial support, the only viable financial option is to develop a substantial private practice that cross-subsidizes the practice of trauma and critical care. The appropriate professional bodies should incorporate changes in work processes that will allow the specialty to survive professionally but also financially.

The association between trauma system and trauma center components and outcome in a mature regionalized trauma system

BACKGROUND

Regionalized trauma systems have been shown repeatedly to improve the outcome of seriously injured patients. However, we do not have data regarding which components of these systems have the most impact on outcome and to what degree. The objective of this study was to understand the association between various components that make up a trauma system and outcome.

METHODS

Surveys were administered to trauma directors at 59 hospitals in the province of Quebec, Canada. Data from the surveys were then linked with specific outcome variables obtained from a regionalized trauma database. Specific outcomes were assigned to trauma system- and in-hospital-based components after controlling for injury severity.

RESULTS

Over 4.8 years, 72,073 patients met inclusion criteria. Components found to affect survival after risk adjustment were prehospital notification (OR, 0.61; 95% CI, 0.39-0.94) and the presence of a performance improvement program in that hospital (OR, 0.44; 95% CI, 0.20-0.94). Increased patient volume was associated with a reduction in risk-adjusted mortality (OR, 0.98; 95% CI, 0.97-0.99). Tertiary trauma centers were also associated with a reduction in risk-adjusted mortality compared with both secondary and primary centers (OR, 0.68; 95% CI, 0.48-0.99).

CONCLUSIONS

Improvements in outcome in a regionalized trauma system are secondary to a combination of elements, as well as to the interplay of these elements on each other. Prehospital notification protocols and performance improvement programs appear to be most associated with decreased risk-adjusted odds of death.

Evaluating Trauma Center Quality: Does the Choice of the Severity-Adjustment Model Make a Difference?

CONTEXT

The Major Trauma Outcome Study (MTOS) database was created by the American College of Surgeons over 20 years ago to establish national norms for trauma care. The primary trauma outcome prediction models used for evaluating the quality of trauma care, TRISS and ASCOT (A Severity Characterization of Trauma), were developed using the MTOS database.

OBJECTIVE

First, to determine whether TRISS and ASCOT agree on hospital quality. Second, to determine whether TRISS and ASCOT accurately reflect contemporary outcomes in trauma care.

DESIGN, SETTING AND PATIENTS

A retrospective cohort study based on 91,112 patients admitted to 69 hospitals between 2000 and 2001 in the National Trauma Databank. Using TRISS and ASCOT, the ratio of the observed to expected mortality rate (O/E ratio) was calculated for each hospital. Hospitals whose O/E ratio was statistically different from 1 were identified as quality outliers. Kappa analysis was used to assess the degree to which TRISS and ASCOT agreed on the identity of hospital quality outliers.

RESULTS

TRISS and ASCOT disagreed on the outlier status of 35 of the 69 hospitals. Kappa analysis revealed only fair agreement (kappa = 0.23; p = 0.0015) between TRISS and ASCOT in identifying quality outliers. Thirty-eight hospitals were identified by the TRISS method as high-performance hospitals.

CONCLUSION

First, TRISS and ASCOT exhibit substantial disagreement on the identity of quality outliers within the NTDB. Second, an unrealistically high number of hospitals were identified as high-performance outliers using either TRISS or ASCOT. These findings have important implications for the use of TRISS and ASCOT for benchmarking performance and quality improvement.

Trauma and Emergency Surgery: An Evolutionary Direction for Trauma Surgeons

BACKGROUND

The success of nonoperative management of injuries has diminished the operative experience of trauma surgeons. To enhance operative experience, our trauma surgeons began caring for all general surgery emergencies. Our objective was to characterize and compare the experience of our trauma surgeons with that of our general surgeons.

METHODS

We reviewed records to determine case diversity, complexity, time of operation, need for intensive care unit care, and payor mix for patients treated by the trauma and emergency surgery (TES) surgeons and elective practice general surgery (ELEC) surgeons over a 1-year period.

RESULTS

TES and ELEC surgeons performed 253 +/- 83 and 234 +/- 40 operations per surgeon, respectively (p = 0.59). TES surgeons admitted more patients and performed more after-hours operations than their ELEC colleagues. Both groups had a mix of cases that was diverse and complex.

CONCLUSION

Combining the care of patients with trauma and general surgery emergencies resulted in a breadth and scope of practice for TES surgeons that compared well with that of ELEC surgeons.