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General Surgeons and trauma
Injury, Int. J. Care Injured 34 (2003) 484–486
General Surgeons and trauma A questionnaire survey of General Surgeons training in ATLS® and involvement in the trauma team Adam Brooks a,∗ , James Williams b , William Butcher c , James Ryan d a Section of Surgery, Queens Medical Centre, Nottingham NG7 2UH, UK Department of Orthopaedic Surgery, Northern General Hospital, Sheffield, UK Department of General and Vascular Surgery, Royal Bournemouth Hospital, Bournemouth, UK d Department of Conflict Recovery, University College, London, UK b
c
Accepted 22 November 2002
Abstract Objective: To determine the level of training of General Surgeons in the UK in the Advanced Trauma Life Support® (ATLS® ) course and their involvement with hospital trauma teams. Methods: Postal questionnaire sent to General Surgical Consultants and Higher Surgical Trainees (HSTs). Results: 58% of General Surgeons who responded had attended ATLS® , but only 30% of those who had been Consultants for more than 10 years. Eighty-seven percent considered the course ‘essential’ or ‘some value’. Sixty-one percent of hospitals represented had a trauma team. A Consultant General Surgeon was a member of the team in 50% and the General Surgical HST in 82%. Conclusion: ATLS® has been widely accepted by General Surgical Trainees and recently appointed Consultants. The trauma team approach to resuscitation has yet to become fully established in the UK and there is limited input from Consultant General Surgeons. © 2003 Elsevier Science Ltd. All rights reserved.
1. Introduction The necessity of General Surgical involvement in the management of trauma in the UK has previously been brought into question [1], however the report from the Royal College of Surgeons of England and the British Orthopaedic Association in 2000 suggested that an experienced, fully trained General Surgeon was an essential member of the trauma team. This report also recommended that all hospitals that managed major trauma patients should establish a functioning 24 h trauma team to receive seriously injured patients and that medical members of the team should be trained to Advanced Trauma Life Support® (ATLS® ) standard. Although the ATLS® course has proven to be very successful in the UK and more than 15 000 British doctors have been trained in the approach and skills that it recommends, information on the acceptance of the course by the different hospital specialities is unknown. Similarly there is only limited information on the introduction of trauma teams and the development of a team approach to trauma ∗ Corresponding author. Tel.: +44-115-924-9924; fax: +44-115-970-9428. E-mail address: [email protected] (A. Brooks).
management in UK Accident & Emergency Departments [2]. General surgery has progressively become more subspecialised and to an extent moved away from a close involvement with the management of trauma, a situation worsened by previous questioning of their requirement in resuscitation. This study was designed to look at the integration of the trauma team approach in resuscitation in the UK, and the training in ATLS® and involvement of General Surgeons within the trauma team. 2. Methods A questionnaire was designed that addressed the involvement of General Surgeons in a functioning hospital trauma team and their training in ATLS® and attitudes towards this course. Questionnaires were sent to General Surgical Consultants and Higher Surgical Trainees (HSTs) in the UK using mailing lists compiled by the Association of Surgeons of Great Britain and Ireland and the Association of Surgeons in Training. Data was analysed and statistical interpretation performed using STATA Version 7. Percentages were calculated in relation to the response to each question as applicable.
0020-1383/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(02)00413-8
A. Brooks et al. / Injury, Int. J. Care Injured 34 (2003) 484–486 Table 1 Grade and experience of respondent Consultants more than 10 years (C > 10) Consultants less than 10 years (C < 10) Higher Surgical Trainees (HSTs) Unknown grade
333 258 245 18
485
Sixty-one percent of the 239 hospitals represented by doctors who answered the questionnaire study had a functioning trauma team. In 50% of the trauma teams the Consultant General Surgeon on call was a member of the team, whilst the General Surgical HST was a participant in 82% of the hospital trauma teams.
3. Results
4. Discussion
A total of 854 (48%) of the 1797 dispatched questionnaires were returned. Table 1 shows the respondents stratified by grade and experience. Seventy-six percent of respondents professed an interest in the management of trauma patients. Significantly more HSTs (89%) than Consultants of greater than 10 years experience (67%) indicated an interest in trauma management (χ2 = 34.5; d.f. = 1; P < 0.0001). An ATLS® course had been completed by 58% of the respondents. The attendance by grade is shown in Fig. 1. General Surgeons who expressed an interest in trauma were more likely to have attended ATLS® (70%) than those who were not interested in trauma (36%) (P < 0.001). Ten percent of the respondents were ATLS® instructors. The opinion of the surgeons who had attended ATLS® on the value of the course is presented in Fig. 2.
In the UK, trauma accounts for 12 000 deaths [13] and approximately 10 000 multiple injuries per year [3]. ATLS® was introduced in the UK in 1988 as part of the response to the Royal College of Surgeons working party report on the management of trauma in the UK [4]. The course is held in high regard [5] and General Surgeons are no exception to this view. International studies have shown that the introduction of ATLS® improves the outcome of trauma patients [6]. In the UK there has been an improvement in trauma care and a reduction in the number of preventable deaths during this time [7], however this is likely to be multifactorial. Trauma teams are an efficient method of managing trauma resuscitation [8,9], especially if task allocation is horizontally organised [10]. The presence of a nominated team leader further improves decision making and the development of a definitive plan [11]. The response rate from our postal questionnaire was 48%. Whilst this level of response is typical for previous postal studies even amongst surgeons with a stated interest in trauma [12], we acknowledge that this may introduce bias to the results towards an apparent increase in General Surgical interest in trauma, ATLS® and the trauma team. Whilst three-quarters of the respondents professed an interest in trauma and were more likely to have attended an ATLS® course than those without a trauma interest, it may well be that the non respondents have less interest in trauma management or ATLS® . This study has shown that nationally the trauma team approach has been accepted by 61% hospitals, which is similar to previously reported regional data [2]. Whilst there is General Surgical contribution from specialist registrars in the majority of these teams, less than a third of hospitals have Consultant General Surgeon input into the trauma team. The requirement for a General Surgeon in the trauma team has been questioned by Bain et al. [1] who suggested that only 25% of injured patients needed General Surgical assessment and 10% surgical intervention. This in turn has been countered by the report ‘Better Care for the Severely Injured’ from the Royal College of Surgeons and British Orthopaedic Association in 2000. The report views the participation of a trained General Surgeon in the receiving team as essential for the immediate assessment of all trauma patients. It is vital that all medical members of the trauma team are trained in ATLS® and nursing staff are trained in the Advanced Trauma Nursing course. This allows a common
Fig. 1. ATLS® attendance by grade of respondent.
Fig. 2. Surgical attitude towards ATLS® .
486
A. Brooks et al. / Injury, Int. J. Care Injured 34 (2003) 484–486
language and approach that facilitates an efficient resuscitation. It is apparent that ATLS® is becoming integrated into UK General Surgical culture although there is currently a shortfall of Consultants who have attended the course. As ATLS® trained specialist registrars filter through the training system this will improve. However, at present senior General Surgical leadership in trauma management and resuscitation in the UK is limited. If General Surgeons are to play a major role in the management of the severely injured patient in the UK then more Consultants need to be trained in ATLS® . The introduction of ATLS® as a component of revalidation for Consultant Surgeons may be one way to achieve this aim. In addition more hospitals must establish a trauma team and General Surgical Consultants need to increase their involvement with these teams if the standards of care that have been set are to be attained.
Acknowledgements The faculty of the Definitive Surgical Trauma Skills course and the Raven Department of Education of the Royal College of Surgeons of England are gratefully acknowledged. References [1] Bain IM, Kirby RM, Cook AL, Oakley PA, Templeton J. Role of General Surgeons in a British Trauma Centre. Br J Surg 1996;83(9):1248–51.
[2] Davis RM, Britten S. The impact of trauma teams on basic surgical training. Ann R Coll Surg Engl 2001;83:21–2. [3] Burdett-Smith P, Airey M, Franks A. Improvement in trauma survival in Leeds. Injury 1995;26:45–8. [4] Royal College of Surgeons. Report of the working party on the management of patients with major injuries. 1989. [5] Campbell B, Heal J, Evans S, Marriott S. What do trainees think about Advanced Trauma Life Support® (ATLS® )? Ann R Coll Surg Engl 2000;82(4):263–7. [6] Ali J, Adam R, Butler AK, Chang H, Howard M, Gonsalves D, et al. Trauma outcome improves following the Advanced Trauma Life Support program in a developing country. J Trauma 1993;34: 890–8. [7] Lecky F, Woodford M, Yates DW. Trends in trauma care in England and Wales 1989–1997. Lancet 2000;355:1771–5. [8] Spencer JD, Gopalji B. Audit of 6 months activity of a trauma team. Injury 1990;21:68–70. [9] Petrie D, Lane P, Stewart TC. An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. J Trauma 1996;41:870–5. [10] Driscoll PA, Vincent CA. Variation in trauma resuscitation and its effect on patient outcome. Injury 1992;23:111–5. [11] Hoff WS, Reilly PM, Rotondo MF, DiGiacomo JC, Schwab WC. The importance of the command—physician in trauma resuscitation. J Trauma 1997;43:772–7. [12] Fakhry SM, Watts D. What’s a trauma surgeon worth? A salary survey of the eastern association for the surgery of trauma. J Trauma 2000;49(5):833–8. [13] Mortality statistics. Injury and poisoning 1993 and 1994. Series DH4 no. 19. London: HMSO; 1997.
General Surgeons and trauma A questionnaire survey of General Surgeons training in ATLS® and involvement in the trauma team Adam Brooks a,∗ , James Williams b , William Butcher c , James Ryan d a Section of Surgery, Queens Medical Centre, Nottingham NG7 2UH, UK Department of Orthopaedic Surgery, Northern General Hospital, Sheffield, UK Department of General and Vascular Surgery, Royal Bournemouth Hospital, Bournemouth, UK d Department of Conflict Recovery, University College, London, UK b
c
Accepted 22 November 2002
Abstract Objective: To determine the level of training of General Surgeons in the UK in the Advanced Trauma Life Support® (ATLS® ) course and their involvement with hospital trauma teams. Methods: Postal questionnaire sent to General Surgical Consultants and Higher Surgical Trainees (HSTs). Results: 58% of General Surgeons who responded had attended ATLS® , but only 30% of those who had been Consultants for more than 10 years. Eighty-seven percent considered the course ‘essential’ or ‘some value’. Sixty-one percent of hospitals represented had a trauma team. A Consultant General Surgeon was a member of the team in 50% and the General Surgical HST in 82%. Conclusion: ATLS® has been widely accepted by General Surgical Trainees and recently appointed Consultants. The trauma team approach to resuscitation has yet to become fully established in the UK and there is limited input from Consultant General Surgeons. © 2003 Elsevier Science Ltd. All rights reserved.
1. Introduction The necessity of General Surgical involvement in the management of trauma in the UK has previously been brought into question [1], however the report from the Royal College of Surgeons of England and the British Orthopaedic Association in 2000 suggested that an experienced, fully trained General Surgeon was an essential member of the trauma team. This report also recommended that all hospitals that managed major trauma patients should establish a functioning 24 h trauma team to receive seriously injured patients and that medical members of the team should be trained to Advanced Trauma Life Support® (ATLS® ) standard. Although the ATLS® course has proven to be very successful in the UK and more than 15 000 British doctors have been trained in the approach and skills that it recommends, information on the acceptance of the course by the different hospital specialities is unknown. Similarly there is only limited information on the introduction of trauma teams and the development of a team approach to trauma ∗ Corresponding author. Tel.: +44-115-924-9924; fax: +44-115-970-9428. E-mail address: [email protected] (A. Brooks).
management in UK Accident & Emergency Departments [2]. General surgery has progressively become more subspecialised and to an extent moved away from a close involvement with the management of trauma, a situation worsened by previous questioning of their requirement in resuscitation. This study was designed to look at the integration of the trauma team approach in resuscitation in the UK, and the training in ATLS® and involvement of General Surgeons within the trauma team. 2. Methods A questionnaire was designed that addressed the involvement of General Surgeons in a functioning hospital trauma team and their training in ATLS® and attitudes towards this course. Questionnaires were sent to General Surgical Consultants and Higher Surgical Trainees (HSTs) in the UK using mailing lists compiled by the Association of Surgeons of Great Britain and Ireland and the Association of Surgeons in Training. Data was analysed and statistical interpretation performed using STATA Version 7. Percentages were calculated in relation to the response to each question as applicable.
0020-1383/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(02)00413-8
A. Brooks et al. / Injury, Int. J. Care Injured 34 (2003) 484–486 Table 1 Grade and experience of respondent Consultants more than 10 years (C > 10) Consultants less than 10 years (C < 10) Higher Surgical Trainees (HSTs) Unknown grade
333 258 245 18
485
Sixty-one percent of the 239 hospitals represented by doctors who answered the questionnaire study had a functioning trauma team. In 50% of the trauma teams the Consultant General Surgeon on call was a member of the team, whilst the General Surgical HST was a participant in 82% of the hospital trauma teams.
3. Results
4. Discussion
A total of 854 (48%) of the 1797 dispatched questionnaires were returned. Table 1 shows the respondents stratified by grade and experience. Seventy-six percent of respondents professed an interest in the management of trauma patients. Significantly more HSTs (89%) than Consultants of greater than 10 years experience (67%) indicated an interest in trauma management (χ2 = 34.5; d.f. = 1; P < 0.0001). An ATLS® course had been completed by 58% of the respondents. The attendance by grade is shown in Fig. 1. General Surgeons who expressed an interest in trauma were more likely to have attended ATLS® (70%) than those who were not interested in trauma (36%) (P < 0.001). Ten percent of the respondents were ATLS® instructors. The opinion of the surgeons who had attended ATLS® on the value of the course is presented in Fig. 2.
In the UK, trauma accounts for 12 000 deaths [13] and approximately 10 000 multiple injuries per year [3]. ATLS® was introduced in the UK in 1988 as part of the response to the Royal College of Surgeons working party report on the management of trauma in the UK [4]. The course is held in high regard [5] and General Surgeons are no exception to this view. International studies have shown that the introduction of ATLS® improves the outcome of trauma patients [6]. In the UK there has been an improvement in trauma care and a reduction in the number of preventable deaths during this time [7], however this is likely to be multifactorial. Trauma teams are an efficient method of managing trauma resuscitation [8,9], especially if task allocation is horizontally organised [10]. The presence of a nominated team leader further improves decision making and the development of a definitive plan [11]. The response rate from our postal questionnaire was 48%. Whilst this level of response is typical for previous postal studies even amongst surgeons with a stated interest in trauma [12], we acknowledge that this may introduce bias to the results towards an apparent increase in General Surgical interest in trauma, ATLS® and the trauma team. Whilst three-quarters of the respondents professed an interest in trauma and were more likely to have attended an ATLS® course than those without a trauma interest, it may well be that the non respondents have less interest in trauma management or ATLS® . This study has shown that nationally the trauma team approach has been accepted by 61% hospitals, which is similar to previously reported regional data [2]. Whilst there is General Surgical contribution from specialist registrars in the majority of these teams, less than a third of hospitals have Consultant General Surgeon input into the trauma team. The requirement for a General Surgeon in the trauma team has been questioned by Bain et al. [1] who suggested that only 25% of injured patients needed General Surgical assessment and 10% surgical intervention. This in turn has been countered by the report ‘Better Care for the Severely Injured’ from the Royal College of Surgeons and British Orthopaedic Association in 2000. The report views the participation of a trained General Surgeon in the receiving team as essential for the immediate assessment of all trauma patients. It is vital that all medical members of the trauma team are trained in ATLS® and nursing staff are trained in the Advanced Trauma Nursing course. This allows a common
Fig. 1. ATLS® attendance by grade of respondent.
Fig. 2. Surgical attitude towards ATLS® .
486
A. Brooks et al. / Injury, Int. J. Care Injured 34 (2003) 484–486
language and approach that facilitates an efficient resuscitation. It is apparent that ATLS® is becoming integrated into UK General Surgical culture although there is currently a shortfall of Consultants who have attended the course. As ATLS® trained specialist registrars filter through the training system this will improve. However, at present senior General Surgical leadership in trauma management and resuscitation in the UK is limited. If General Surgeons are to play a major role in the management of the severely injured patient in the UK then more Consultants need to be trained in ATLS® . The introduction of ATLS® as a component of revalidation for Consultant Surgeons may be one way to achieve this aim. In addition more hospitals must establish a trauma team and General Surgical Consultants need to increase their involvement with these teams if the standards of care that have been set are to be attained.
Acknowledgements The faculty of the Definitive Surgical Trauma Skills course and the Raven Department of Education of the Royal College of Surgeons of England are gratefully acknowledged. References [1] Bain IM, Kirby RM, Cook AL, Oakley PA, Templeton J. Role of General Surgeons in a British Trauma Centre. Br J Surg 1996;83(9):1248–51.
[2] Davis RM, Britten S. The impact of trauma teams on basic surgical training. Ann R Coll Surg Engl 2001;83:21–2. [3] Burdett-Smith P, Airey M, Franks A. Improvement in trauma survival in Leeds. Injury 1995;26:45–8. [4] Royal College of Surgeons. Report of the working party on the management of patients with major injuries. 1989. [5] Campbell B, Heal J, Evans S, Marriott S. What do trainees think about Advanced Trauma Life Support® (ATLS® )? Ann R Coll Surg Engl 2000;82(4):263–7. [6] Ali J, Adam R, Butler AK, Chang H, Howard M, Gonsalves D, et al. Trauma outcome improves following the Advanced Trauma Life Support program in a developing country. J Trauma 1993;34: 890–8. [7] Lecky F, Woodford M, Yates DW. Trends in trauma care in England and Wales 1989–1997. Lancet 2000;355:1771–5. [8] Spencer JD, Gopalji B. Audit of 6 months activity of a trauma team. Injury 1990;21:68–70. [9] Petrie D, Lane P, Stewart TC. An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. J Trauma 1996;41:870–5. [10] Driscoll PA, Vincent CA. Variation in trauma resuscitation and its effect on patient outcome. Injury 1992;23:111–5. [11] Hoff WS, Reilly PM, Rotondo MF, DiGiacomo JC, Schwab WC. The importance of the command—physician in trauma resuscitation. J Trauma 1997;43:772–7. [12] Fakhry SM, Watts D. What’s a trauma surgeon worth? A salary survey of the eastern association for the surgery of trauma. J Trauma 2000;49(5):833–8. [13] Mortality statistics. Injury and poisoning 1993 and 1994. Series DH4 no. 19. London: HMSO; 1997.