Contemporary SurgeryREAL WORLD
Is acute-care surgery the answer John
for trauma call?
Department of Surgery, Medical University of South Carolina, Charleston
Should general surgeons or trauma-trained specialists be providing coverage?
Who should take trauma call? In the age of specialization and outcome-driven evaluation of care, the answer seems obvious. Certain diseases have seen improved outcomes and reduced complications at high-volume “centers of excellence”, where surgeons are familiar with complex procedures and specialized perioperative care.1-9 Translation of these findings suggests that trauma-trained specialists would best handle trauma patients.
Our institution, the Medical University of South Carolina Hospital, is the only Level I trauma center in a 100-mile radius. Three trauma/critical care-trained surgeons share most of the coverage to treat more than 2500 trauma patients a year. Every fifth evening, other subspecialty department members chip in. As in most trauma centers, the volume is simply too great for the few specialists to manage alone.
A hybrid acute-care specialty
About 70% of the 1000 annual graduates of general surgery residencies pursue subspecialty training.10 Fewer choose trauma/critical care. Only 66 positions (48%) in the surgical critical care specialty match filled in 2008 (BOX).11
The volume is too great for the small number of trauma-trained specialists to manage alone.
Most academic trauma centers have developed a hybrid of acute-care surgery, trauma surgery, and critical care to try to broaden the scope of practice for the trauma surgeon and attract more candidates.13,14 The American Association for the Surgery of Trauma (AAST) has proposed an acute care surgical fellowship curriculum.15
Obstacles residents face in choosing trauma subspecialty
Residents related these obstacles to choosing a trauma/critical care subspecialty:12
The problem with specialization
Surgical specialization has created a new problem: Surgeons who complete fellowships become compartmentalized—they no longer feel comfortable treating trauma patients, nor do they want to.
In a recent study, 85% of British general surgeons said major trauma should only be directed to trauma centers. While 90% had confidence in their ability to manage trauma, that number dropped when asked about these specific injuries:16
We suspect similar trends would be seen in a survey of specialty-trained surgeons in the United States.
The only variable linked to improved patient survival and outcome was the number of trauma patients a center treated.
Not enough coverage
The low number of trauma/critical-care specialists has created a significant problem: Many hospitals cannot provide 24-hour coverage. The National Trauma Institute estimated 160,000 trauma-related deaths occurred in the United States in 2007.17
Unintentional injuries are the fifth leading cause of death, and the leading cause of young patient deaths.18 In 2003, 40 million people were treated in emergency departments. Almost 3 million were hospitalized for unintentional injuries.19 These numbers will likely rise as the population grows, further exacerbating coverage issues.20
Regionalize trauma care?
The National Study on the Costs and Outcomes of Trauma (NSCOT) identified differences in treatment at Level I trauma centers versus non-trauma centers.21 Risk of death was 25% lower in the most severely injured younger patients treated at trauma centers. Better outcomes were shown in patients with major lower-limb trauma treated at a Level I trauma center.22
Level I trauma centers had a lower mortality in patients with cardiovascular and severe liver injuries (grades IV and V, AAST liver injury scale), and a lower disability rate in patients with complex pelvic fractures compared with Level II centers.23
This suggests a trend toward improved outcomes in other trauma patient subsets: high-energy neuro-trauma, upper-extremity trauma, cardiothoracic, and vascular injuries. Variables that influenced good outcomes are:
Quantity. Improvements in mortality and length of stay in shock and coma patients occurred in centers with more than 650 trauma admissions a year.24 The number of trauma patients a center treated was the only variable linked to improved outcomes. Level of accreditation, presence of an “in-house” trauma attending, surgical residency, or medical school affiliation were not.25
Type of injury. High-volume centers showed a higher survival rate for 7 of 9 injury types compared with the predicted value defined by a severity characterization of trauma score (ASCOT).25 This suggests severely injured patients in shock benefit from trauma center treatment.
Specialty. Higher mortality was shown in injured patients treated by general surgeons taking trauma call than by a full-time trauma group.26
These findings, however, cloud the picture:
Volume. No difference was found in mortality and length of stay between high- and low-volume Level I and II trauma centers.27 Mortality rates of trauma patients with injury severity scores (ISS) greater than 15 were no different between high- and low-volume centers (Levels I, II, III).28 Neither study accounted for physiologic parameters in mortality and length of stay.
Caseload. A negative correlation was found between trauma center volume and survival. Surgeon caseload had no effect on survival rates.29
Mortality rates in patients with a similar ISS were no different if treated by high-volume trauma surgeons or low-volume specialists.30 High-volume trauma surgeons were defined as treating more than 35 patients per year with an ISS greater than 15.31
Improved survival and outcomes for severely injured, critically ill patients treated at high-volume Level I trauma centers is likely multifactorial. The trend may depend on intrinsic support systems within academic trauma centers as well as trauma surgeons’ increased experience.
Trauma surgeons can take heart that their specialized care and 40-plus years of research have led to improved survival and functional outcomes. This, however, does not mandate that trauma care must be the exclusive responsibility of trauma surgeons.
Physician cooperation, institutional commitment, and improved government funding are needed to help solve this crisis.
Although trauma is a universal problem, few physicians are trained to care for critically injured patients. The growing trauma coverage crisis requires a collaborative effort among the following groups:
Physicians and staff. Trauma, general, and subspecialty surgeons must continue to cooperate in a team approach to provide excellent care.
Institutions. Institutional commitment is critical to successful care. Hospitals must develop and maintain the necessary infrastructure and staff to support surgeons taking call.
Government. Improved state and federal funding are needed to ensure adequate resources and coverage.
The authors did not disclose any relationships.
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, et al.
Association of volume with outcome of coronary artery bypass graft surgery. Scheduled vs nonscheduled operations.
Wennberg, Potential benefits of regionalizing major surgery in Medicare patients.
Eff Clin Pract. 1999;2:277–283.
Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy.
Ann Surg. 1995;222:638–645.
Major HPB procedures must be undertaken in high volume quaternary centres?
HPB Surg. 2000;11:359–361.
Results of elective abdominal aortic aneurysm repair in the 1990s: A population-based analysis of 2335 cases.
J Vasc Surg. 1999;30:985–995.
Center volume effects in pediatric renal transplantation. A report of the North American Pediatric Renal Transplant Cooperative Study.
Pediatr Nephrol. 1999;13:373–378.
, et al.
The effect of transplant center volume on cardiac transplant outcome. A report of the United Network for Organ Sharing Scientific Registry.
The relation between experience and outcome in heart transplantation.
N Engl J Med. 1992;327:1220–1225.
, et al.
The relationship between hospital volume and outcome in bariatric surgery at academic medical centers.
Ann Surg. 2004;240:586–594.
Progressive specialization within general surgery: adding to the complexity of workforce planning.
J Am Coll Surg, 2005;201(6):925–932.
- Match Results Statistics Surgical Critical Care Match.
National Resident Matching Program. 2008. Available at: http://www.nrmp.org/fellow/match_name/surg_crit_care/stats.html. Accessed September 8, 2008.
The shape of things to come: results from a national survey of trauma surgeons on issues concerning their future.
J Trauma. 2006;60:8–16.
Acute care surgery: Eraritjaritjaka.
J Am Coll Surg. 2006;202:698–701.
- Committee to Develop the Reorganized Specialty of Trauma Surgical Critical Care
and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery.
J Trauma. 2005;58:614–616.
- Acute Care Surgery Curriculum.
Trauma Source: The American Association for the Surgery of Trauma. 2008. Available at: http://www.aast.org/acute_care_surgery.aspx?id=1250. Accessed September 8, 2008.
, et al.
The experience and training of British general surgeons in trauma surgery for the abdomen, thorax and major vessels.
Ann R Coll Surg Engl. 2002;84:409–413.
- Research FAQs.
National Trauma Institute. Available at: http://www.nationaltraumainstitute.com/faq.asp. Accessed September 8, 2008.
- LCWK9 Deaths, percent of total deaths, and Death rates for the 15 leading causes of death: 2005.
Centers for Disease Control and Prevention, National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/datawh/statab/unpubd/mortabs/lcwk9_10.htm. Accessed September 8, 2008.
- Injury Facts.
National Safety Council. Available at: http://www.nsc.org/lrs/injuriesinamerica08.aspx. Accessed on September 8, 2008.
Acute care surgery: the general surgeon’s perspective.
, et al.
A national evaluation of the effect of trauma-center care on mortality.
N Engl J Med. 2006;354:366–378.
, et al.
The impact of trauma-center care on functional outcomes following major lower-limb trauma.
J Bone Joint Surg Am. 2008;90:101–109.
, et al.
The effect of trauma center designation and trauma volume on outcome in specific severe injuries.
Ann Surg. 2005;242:512–519.
The relationship between trauma center volume and outcome.
Adv Surg. 2001;35:61–75.
Outcome analysis of Pennsylvania trauma centers: factors predictive of nonsurvival in seriously injured patients.
J Trauma. 2001;50:465–474.
Injured patients have lower mortality when treated by “full-time” trauma surgeons vs. surgeons who cover trauma “parttime”.
J Trauma. 2006;61:272–279.
Is there a relationship between trauma center volume and mortality?
J Trauma. 2003;54:16–25.
The relation between trauma center outcome and volume in the National Trauma Databank.
J Trauma, 2004;56:682–690.
, et al.
Patient volume per surgeon does not predict survival in adult Level I trauma centers.
J Trauma. 2001;50:597–603.
Does volume matter? The effect of trauma surgeons’ caseload on mortality.
J Trauma. 2003;54:829–834.
- American College of Surgeons Committee on Trauma.
Resources for Optimal Care of the Injured Patient. Chicago: American College of Surgeons; 2006.