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Is There Evidence to Support the Need for Routine Surgeon Presence on Trauma Patient Arrival?
TRAUMA/CONCEPTS
Is There Evidence to Support the Need for Routine Surgeon Presence on Trauma Patient Arrival? Steven M. Green, MD
From the Department of Emergency Medicine, Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA.
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. [Ann Emerg Med. 2006;47:405-411.] 0196-0644/$-see front matter Copyright © 2006 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2005.11.032
SEE RELATED EDITORIAL, P. 413. INTRODUCTION A central tenet of the American College of Surgeons’ (ACS) paradigm of trauma care is that “the general surgeon serves as the captain of the resuscitating team and is expected to be in the emergency department [ED] upon arrival of the seriously injured patient.”1 Indeed, compliance with this precept is mandated to obtain or maintain trauma center certification.1 Hospitals wishing such designations typically expend substantial resources to recruit and maintain a continuous call panel of surgeons capable of rapid ED response. The basis of this requisite is, of course, the inherent presumption that a surgeon awaiting the arrival of the patient improves trauma outcomes. Certainly there are patients for whom the earliest possible attendance by a surgeon can prove lifesaving; for example, those requiring emergency operative intervention for truncal penetrating trauma or persistent shock. However, in many settings such scenarios are increasingly unusual, and the specific incremental benefit of requiring a surgeon to be routinely present for each trauma team activation, rather than for just a well-defined subset of these patients, may be small relative to the substantial associated costs. Indeed, it would not Volume , . : May
appear to be efficient or professionally satisfying to require general surgeons to interrupt their other duties to attend patients unlikely to require their urgent intervention, such as those with isolated head or orthopedic injuries. In this article, I critically appraise this specific trauma center requirement in terms of its historical basis, its supporting evidence, its contrast with alternative systems outside of the United States, and its perception by trauma surgeons. I then discuss potential future changes to this requirement in the context of this background. This article is focused solely on the issue of mandatory surgeon presence on trauma patient arrival; it is presumed self evident that a single service skilled in definitive trauma management should oversee the postresuscitative evaluation and treatment for admitted patients. In preparing this article, I searched MEDLINE (through 2005 using search terms “attending trauma surgeon,” “trauma attending,” “in-house trauma,” and “secondary triage”), manually searched the tables of contents of the leading emergency medicine and surgery journals (1995 to 2005), and widely consulted emergency physician and surgical colleagues with special interest in trauma care. I searched the reference lists of all identified articles for additional relevant articles. Annals of Emergency Medicine 405
Routine Surgeon Presence on Trauma Patient Arrival
SCOPE OF THE REQUIREMENT The ACS stipulates that the presence of an attending general surgeon in the ED on patient arrival (presuming sufficient advance notification) is “essential” for all “major” resuscitations in trauma centers designated as Level I, II, or III.1 Hospitals may formulate their own criteria for surgeon involvement; however, at a minimum surgeons must be summoned for socalled major criteria: confirmed hypotension; respiratory compromise or intubation; gunshot wounds to the abdomen, neck, or chest; or a Glasgow Coma Scale score less than 8.2 In typical practice, most trauma centers activate teams for a far wider range of criteria than these, for philosophical, practical, and logistical considerations. Philosophically, there is a natural inclination of those writing the activation criteria to overtriage to minimize the prospect of missing serious injuries. Practically speaking, there is rarely time in most urban out-of-hospital systems for purported hypotension to be “confirmed” in the field, and if any doubt exists about the interpretation of activation guidelines, ED nurses communicating by radios are likely to be conservative and err on the side of activation. Logistically, trauma services are under ongoing pressure from hospital administrators to demonstrate that their patient care load is sufficient to warrant their existing level of resources, and the most straightforward way to increase volume is to expand activation criteria. Hospitals rarely object because the fees associated with trauma team activations are often substantial, and such revenue from insured patients helps offset corresponding losses for uninsured patients.3 The overall societal costs associated with such unduly generous use of trauma teams are enormous.
HISTORICAL BASIS AND EVOLUTION Before the late 1970s, most trauma victims were simply transported to the nearest ED regardless of the severity of their injuries or of the capabilities of the receiving hospital. As the ACS championed and promulgated the trauma center concept, they found 2 potent reasons to demand early surgeon involvement in trauma care. First, operative management was common. In that era, most patients with substantial blunt abdominal trauma routinely underwent diagnostic peritoneal lavage, which, if it yielded a positive result, mandated laparotomy. Surgeons regularly whisked injured victims to the operating room to explore abdomens and remove spleens within the then-touted “golden hour.”4 Second, surgeons were justifiably alarmed by the inconsistent trauma expertise of physicians staffing EDs in the late 1970s, primarily internists, family physicians, and residency dropouts. Indeed, the venerable Advanced Trauma Life Support course was inspired by an occurrence of “inadequate” care by such practitioners.5 The routine early involvement of surgeons was then viewed as essential to ensure that patients would be treated by practitioners competent in trauma care. A quarter century of medical evolution has fundamentally altered the landscape surrounding these 2 premises. Dramatic 406 Annals of Emergency Medicine
Green advances in the speed and resolution of computed tomography have largely obviated the need for “exploratory” surgery; indeed, even in the setting of radiographically documented intraabdominal injury most blunt trauma patients can now be safely treated nonoperatively.6-9 The practice of trauma surgery has transitioned from the invigoration of frequent “emergency” laparotomies to fairly routine and increasingly protocol-driven ward management.6,7,9-12 During this same quarter century, the specialty of emergency medicine has not just matured but also prospered. Emergency medicine residencies have been highly competitive for 2 decades. Most EDs serving trauma centers are now routinely staffed with emergency medicine residency graduates who are well trained and adept at trauma resuscitation and its associated procedures.
THE EVIDENCE Few researchers have focused their attention on the incremental value of having a surgeon routinely present during trauma resuscitations. Research that can be interpreted as bearing on this issue can be divided into between-hospital comparisons, within-hospital comparisons, retrospective assessment of surgeon involvement, and secondary triage schemes. A first caveat is that I discuss this research with a focus on patient-oriented rather than disease-oriented outcomes.13 The former refer to outcomes that matter to patients, which in the setting of trauma are primarily decreased mortality and morbidity. Disease-oriented outcomes, on the other hand, refer to intermediate or surrogate findings that may or may not translate into patient-oriented improvement. For example, some studies in this section report disease-oriented improvements (eg, faster time to the operating room, fewer errors in judgment) in the absence of patient-oriented improvement. Such findings are naturally less compelling than those that are patient-oriented. A second caveat is that I emphasize primary study objectives rather than secondary results reported from post hoc subset analyses. The latter are common in this set of literature, and their results are often strongly emphasized by their authors. However, it is well accepted that such post hoc comparisons are statistically prone to false-positive results and should be regarded with substantial skepticism.14,15 Finally, I do not discuss the research detailing decreases in trauma-related mortality over time, often concurrent with the implementation of specific trauma systems. Such research lacks the ability to isolate the incremental value of mandatory trauma surgeon presence. Potent confounding variables include the formalization of comprehensive trauma center resources (eg, specialist call, operating room mobilization, radiology and rehabilitation capabilities). Further, baseline mortality rates are known to be gradually improving over time because of improved traffic safety, decreased violent crime, and injury prevention initiatives.8,16,17 Volume , . : May
Green Between-Hospital Comparisons Three sets of investigators have compared trauma outcomes between hospitals using in-house surgeons and those permitting surgeons to take calls from home, based on the logical premise that the former group should be able to respond more quickly to trauma team activations and be more consistently present on patient arrival. In the first study, Rogers et al18 compared an urban hospital with in-house surgeons to a rural hospital in a different state with on-call surgeons. Overall mortality was similar between hospitals; however, more “errors in judgment” were noted at the rural hospital based on a nonblinded medical record review without explicit definitions. This study is confounded by the differences that would be expected between urban and rural locations in terms of patient population, out-of-hospital transport times, and the quantity and quality of supporting hospital resources. Demarest et al19 compared 2 tertiary trauma centers, one with in-house surgeons and one with out-of-hospital surgeons, and did not observe any differences in mortality or other outcomes. However, they report that their on-call surgeons (who all lived within 10 minutes) responded to the ED as quickly on average as the in-house group, and thus their results cannot address the issue of routine surgeon participation. The study of this format with the greatest relevance to the incremental value of surgeon presence is that of Khetarpal et al,20 who compared one hospital with in-house trauma attending physicians to another where surgeons were out-ofhospital and not typically involved until after the initial evaluation and resuscitation. They noted that the in-house group took their patients to the operating room more quickly than the on-call group for the subset of patients with penetrating trauma; however, there was no difference in overall mortality or other patient-oriented outcome to confirm any benefit from early surgeon involvement. A caveat about the above studies is that they compare only the role of trauma surgery attending physicians because in-house surgery residents were involved in patient care in both groups. Although the presence of residents might have diluted any adverse impact from the absence of attending surgeons, few would argue the suitability or advisability of substituting stafflevel clinical judgment for that of trainees.18,21 Indeed, the ACS no longer recognizes senior surgical residents as a substitute for surgical staff.1 Within-Hospital Comparisons Whether surgeons are in-house or taking calls from home varies in some trauma centers by the time of day or week or is left to the preference of each surgeon. Five investigators have compared trauma outcomes between periods of in-house versus out-of-hospital calls at single hospitals. Thompson et al22 compared trauma care provided during the daytime by in-house surgeons with care provided during evenings and nights when surgeons took calls from home. Mortality was similar between groups; however, their on-call Volume , . : May
Routine Surgeon Presence on Trauma Patient Arrival surgeons were able to respond to the ED as quickly as those in house, and thus the specific contribution of the surgeon themselves could not be isolated. Porter and Ursic23 describe their setting in which 6 of their 8 surgeons routinely took calls from outside the hospital and were not typically present at patient arrival. They reviewed trauma resuscitation flow sheets to divide their experience into patients for whom an attending surgeon was present during the resuscitation (23%) versus those in which this practice was not documented (77%). Although time to the operating room was faster with the in-house group, there were no overall differences in mortality, complications, or length of hospitalization. They report a nonsignificant trend toward fewer “missed” injuries and “inappropriate workup” in the surgeon-present group; however, they provide no explicit definitions for these subjective outcomes or other evidence that this retrospective judgment was performed in a manner likely to be free from bias.24 Although these authors conclude that in-house trauma surgeons are preferred, the ability of their data to support this assertion has been disputed.25 Fulda et al26 compared patients treated at their hospital by full-time faculty surgeons who took in-house calls with those treated by part-time community-practice surgeons who took calls from outside the hospital and were expected to be available within 30 minutes. They noted no difference in mortality (including the subset in which surgeon response was actually ⬎30 minutes), time to operating room, length of hospitalization, or other secondary outcomes. Helling et al27 compared patients treated at their hospital on weekends (when surgery attending physicians were usually in house) with those on nights and weekends (when they were usually out of the hospital but responded in an average of 16 minutes). They found no difference in mortality, complications, time to operating room, or hospital length of stay. ICU length of stay was longer in the in-house group. In the subset with penetrating injuries and shock, there were similarly no differences in mortality, time to the operating room, or other secondary outcomes. The research of this format with the greatest relevance to mandatory surgeon presence is that of Luchette et al,21 whose design was similar to the previous studies, except that their oncall surgeons did not routinely respond until after surgical resident evaluation of the patient. Although they report faster times to the operating room and to diagnostic testing for a subset of their sample (patients treated during the daytime but not during evenings or nights), there was no difference in mortality or ICU length of stay that might confirm any patientoriented benefit from early surgeon involvement. A limitation of the above research comparisons based on time of day or week is that, on average, less severely injured patients may be likely to present during routine weekday inhouse call hours. Further, a limitation of the comparisons based on surgeon preference is that the in-house surgeons are likely to be those more committed to trauma care. In both of these Annals of Emergency Medicine 407
Routine Surgeon Presence on Trauma Patient Arrival circumstances, these biases should create more favorable outcomes for the in-house group and thus exaggerate the apparent benefit of early surgeon involvement. Despite this inherent advantage, however, no such benefit was observed. All of the above studies have the same caveat about the presence of surgery residents mentioned in the last section. Retrospective Assessment of Surgeon Involvement Two sets of researchers have analyzed multicenter trauma registries to assess how frequently early surgeon involvement appeared to be valuable or necessary. In their analysis of 68,558 children (aged ⬍18 years) from the National Trauma Data Bank, Acierno et al28 found that 30.7% of patients ultimately underwent some type of operative procedure, of which the vast majority (89%) were orthopedic. The proportion of blunt trauma patients receiving emergency operative intervention (which they define as within 4 hours of ED arrival) by a general or pediatric surgeon was 3.6% for those aged 13 years or younger and was 5.6% for patients older than 13 years. The fraction of these patients needing such truly emergency interventions (eg, within 1 hour) is not specified, so it is difficult to speculate on what proportion of this sample may have directly benefited from routine surgeon presence on ED arrival. In a similar study, Tepas et al29 analyzed 87,424 cases from the National Pediatric Trauma Registry. They report that 11.4% of these children ultimately underwent some type of operative intervention and that 57.6% had at least 1 so-called surgical injury that they believe warranted evaluation by a surgeon of some specialty. The breakdown of how many of these operative procedures and surgical evaluations were emergency, urgent, or nonurgent is not specified, however, nor is the proportion performed by general or pediatric surgeons rather than orthopedists, neurosurgeons, or others. Thus, these data are also unable to quantify the unique contribution of a trauma surgeon early in each patient’s care. Secondary Triage Field triage criteria are used to determine which patients are transported to trauma centers. However, in many centers not all of these patients receive full trauma team activations with routine surgeon involvement. Instead, predefined criteria are used to “secondary triage” patients into multiple tiers of response. Secondary triage techniques do not divert patients away from trauma centers but rather serve as a mechanism for focusing surgeon attention on those cases most likely to require their unique skills. There are numerous reports of various systems of secondary triage, with lower-risk patients either forgoing surgeon involvement altogether unless requested by the emergency physician30-35 or delaying such consultation until the postresuscitation phase, when time permits.36 These studies have uniformly suggested that such techniques appear accurate and safe while permitting 36% to 72% of patients to avoid needless trauma team activation.30,32,33,35-38 Secondary triage 408 Annals of Emergency Medicine
Green has been shown to decrease ED length of stay33 and to be cost efficient and resource efficient.30,31,33-40 Most of these secondary triage schemes retain physiologic and core anatomic triage criteria (ie, those considered by the ACS to constitute “major” resuscitations2) to activate trauma teams but defer such activations for other low-yield criteria such as mechanism of injury.34,41,42 However, Ciesla et al43 instituted a secondary triage policy deferring surgeon involvement for 1 ACS major resuscitation criterion: respiratory compromise or intubation. Of 489 such patients, just 22 (4%) patients received emergency operative intervention by a trauma surgeon, with 12 of these 22 cases being stab wounds. These authors conclude that after exclusion of stab wounds, field or ED intubation alone rarely leads to emergency surgeon intervention and that “the decision to have the trauma surgeon present upon the patient’s arrival is better made by trained emergency department physicians than a blanket requirement for all intubated patients regardless of physiology.”43
SETTINGS OUTSIDE OF THE UNITED STATES Despite the influence of the ACS on trauma care worldwide, the concept of routine surgeon presence on patient arrival has not been widely accepted outside of the United States. Indeed, in most European countries trauma resuscitations are routinely managed by nonsurgical critical care physicians, and there is no compelling evidence to support any presumed superiority of the American model.44 Nathens et al44 contrast the American and French systems of trauma care and note that, despite higher French motor vehicle fatality rates, there are potent confounding variables that hinder any reliable comparison of quality of care. Canadian trauma center criteria have never mandated routine trauma surgeon presence but instead permit emergency physicians to consult these specialists on an as-needed basis.45 Singh et al46 describe a Canadian system of pediatric trauma care in which patients are treated by emergency physicians with backup by a pediatric intensivist physician available within 5 minutes. Surgeons are not routinely involved but are instead consulted based on the emergency physician evaluation. They report similar morbidity and mortality at American centers.46
TRAUMA SURGEON PERSPECTIVE Modern trauma surgeons are now less tolerant about lifestyle issues.3,7,11,12,47-49 They work “unappealing hours, with a great deal of unpredictability, high stakes and high stress.”50 Ciesla et al43 recently wrote: “As the criteria for major resuscitation are broadened, we spend proportionately more time evaluating patients that could be initially managed by ED physicians trained in trauma care in conjunction with neurosurgeons and orthopedic surgeons. This should not be considered abdication of trauma care to the ED physician but a more appropriate distribution of priorities to qualified personnel.” They continue: “. . .we continue self-imposed mandates that only serve to make our environment less Volume , . : May
Green desirable. In effect, we have become our own worst enemies.” Maier51 echoes this: “. . . our research demonstrates no improvement in patient care by mandating in-house attending trauma coverage. Why do we mandate onerous standards without evidence to support them? To prove how much we can sacrifice?” Similarly, Cryer52 notes that “In point of fact very few patients require the immediate presence of a general surgeon. Well-trained ED physicians are capable of initiating the care of the vast majority of patients.” Further, rapid surgeon response in many settings requires a doubling at minimum of the number of general surgeons on the call roster.47,48 In larger academic centers, this frequently necessitates recruiting general surgeons specialized in areas other than trauma. The resulting “paradox” is that this requirement can lead to more trauma care being delivered by surgeons with limited related interest and experience.47,48 Trauma surgeons are attempting a “facelift” of their subspecialty by reestablishing challenging operative components (eg, vascular, thoracic) to their practice.48,50,53
IMPLICATIONS Given the above background, the premise that trauma outcomes are improved by the routine presence of surgeons on patient arrival must be considered an unproven hypothesis. The 2 historical factors that originally prompted this requirement—frequent exploratory laparotomies and EDs staffed by physicians without trauma training—are no longer realities in most modern trauma centers. Research from multiple centers and in multiple varying formats has repeatedly failed to identify improvement in patient-oriented outcomes from early surgeon involvement. European and Canadian trauma care do not routinely involve surgeons in the resuscitation phase, without any demonstrated or perceived decrease in 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. So given the lack of a compelling basis, why does the routine early arrival of a surgeon remain an ACS certification requirement? The first reason may be that open questioning of this longstanding tradition by surgeons43,51 and emergency physicians46,54 is only a recent phenomenon and that more open debate will be required for all viewpoints to be heard and considered. Second, and more potent, many surgeons likely feel a visceral passion and sense of ownership over trauma care that may be difficult to reconcile with evidence-based medicine. Surgeons indeed deserve immense and complete credit for organizing and implementing our now-precious network of trauma centers, and any action that might scale back their historical routine presence on patient arrival may threaten or symbolize a loss of control or ultimate authority over the process. However, it should not be perceived as a personal affront to trauma surgeons that their Volume , . : May
Routine Surgeon Presence on Trauma Patient Arrival dramatic success in maturing their subspecialty has rendered them less essential minute by minute.
THE FUTURE Given the lack of evidentiary support for the routine presence of surgeons at trauma activations, there would not appear to be an objective reason to retain this certification requirement. Removing or modifying this mandate would provide trauma centers the flexibility they now lack to individualize their secondary triage criteria based on unique local resources, expertise, and caseload distributions. Research resulting from innovative secondary triage strategies will better clarify which trauma patients require either emergency or urgent unique expertise of a general surgeon during the initial phase of trauma management. Should this stipulation be relaxed, it is unlikely that many urban trauma centers would discontinue routine surgeon involvement for trauma victims with truncal penetrating injury or persistent shock. However, factors such as respiratory compromise and intubation or Glasgow Coma Scale score less than 8 in the absence of other major criteria suggest primarily head injury, a situation unlikely to be associated with emergency operative intervention by a general surgeon. Rather than routinely interrupting their other duties to be present on the arrival of such patients, surgeons could instead evaluate this subset in delayed fashion when time permits unless summoned more quickly by the treating emergency physician. The important caveat of any such secondary triage criteria modifications would be that the involved emergency physicians must be willing and able to effectively take up any newly created slack. Despite the near-complete maturation of emergency medicine as a specialty, in some trauma centers the situation may not yet be right for such a change. However, many other such institutions are already staffed with residency-trained emergency physicians with demonstrated competence at trauma resuscitation and its related procedures. Such ED staff are likely to exhibit an ongoing commitment to superior trauma care and the willingness to actively participate in continuous quality improvement. In such centers, surgeons and emergency physicians can likely refine their secondary triage criteria together in a collegial manner that ensures high-quality care but yet more efficiently uses surgeons’ time. An outstanding example of such collaboration has been described by Ciesla et al.43
CONCLUSION The premise that trauma outcomes are improved by the routine presence of surgeons on patient arrival lacks an objective evidentiary basis, despite being an ACS trauma center certification requirement. Future 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 Annals of Emergency Medicine 409
Routine Surgeon Presence on Trauma Patient Arrival permitted the flexibility necessary to perform such research and to use such findings to refine and focus their secondary triage criteria. Supervising editor: Judd E. Hollander, MD Funding and support: The author reports this study did not receive any outside funding or support. Publication dates: Received for publication September 14, 2005. Revision received November 18, 2005. Accepted for publication November 21, 2005. Available online January 18, 2006. Reprints not available from the author. Address for correspondence: Steven M. Green, MD, Loma Linda University Medical Center A-108, 11234 Anderson Street, Loma Linda, CA 92354; 909-558-4085; fax 775-3074121; E-mail [email protected]. REFERENCES 1. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 1999. 2. American College of Surgeons Committee on Trauma. Amendments to Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2000. 3. Rodriguez JL, Christma AB, Franklin GA, et al. Trauma/critical care surgeon: a specialist gasping for air. J Trauma. 2005;59:1-7. 4. Lerner EB, Moscati RM. The golden hour: scientific fact or medical “urban legend”? Acad Emerg Med. 2001;8:758-760. 5. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Manual. 7th ed. Chicago, IL: American College of Surgeons; 2004. 6. Eastern Association for the Surgery of Trauma. EAST ad hoc committee for the development of practice management guidelines: trauma practice guidelines Eastern Association for the Surgery of Trauma. Available at: http:// www.east.org. Accessed September 13, 2005. 7. Richardson JD, Miller FB. Will future surgeons be interested in trauma care? results of a resident survey. J Trauma. 1992;32: 229-233. 8. Engelhardt S, Hoyt D, Coimbra R, et al. The 15-year evolution of an urban trauma center: what does the future hold for the trauma surgeon? J Trauma. 2001;51:633-638. 9. Fakhry SM, Watts DD, Michetti C, et al. The resident experience on trauma: declining surgical opportunities and career incentives? analysis of data from a large multi-institutional study. J Trauma. 2003;54:1-8. 10. Flint LM. Discussion regarding “pediatric trauma is very much a surgical disease.” Ann Surg. 2003;237:780. 11. Richardson JD. Trauma centers and trauma surgeons: have we become too specialized? J Trauma. 2000;48:1-7. 12. Richardson JD. Is there an ideal model for training the trauma surgeons of the future? J Trauma. 2003;54:795-797. 13. Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract. 2004; 17:59-67. 14. Rothwell PM. Subgroup analysis in randomized controlled trials: importance, indications, and interpretation. Lancet. 2005;365: 176-186. 15. Oxman AD, Guyatt GH. A consumer’s guide to subgroup analyses. Ann Intern Med. 1992;116:78-84.
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Green 16. Hulka F, Mullins RJ, Mann NC, et al. Influence of a statewide trauma system on pediatric hospitalization and outcome. J Trauma. 1997;42:514-519. 17. Biffl WL, Harriington DT, Majercik SD, et al. The evolution of trauma care at a level I trauma center. J Am Coll Surg. 2005; 200:922-929. 18. Rogers FB, Simons R, Hoyt DB, et al. In-house board-certified surgeons improve outcome for severely injured patients: a comparison of two university centers. J Trauma. 1993;34:871875. 19. Demarest GB, Scannell G, Sanchez K, et al. In-house versus on-call attending trauma surgeons at comparable level I trauma centers: a prospective study. J Trauma. 1999;46:535540. 20. Khetarpal S, Steinbrunn BS, McGonigal MD, et al. Trauma faculty and trauma team activation: impact on trauma system function and patient outcome. J Trauma. 1999;47:576-581. 21. Luchette F, Kelly B, Davis K, et al. Impact of the in-house trauma surgeon on initial patient care, outcome, and cost. J Trauma. 1997;42:490-495. 22. Thompson CT, Bickell WH, Siemens RA, et al. Community hospital level II trauma center outcome. J Trauma. 1992;32:336341. 23. Porter JM, Ursic C. Trauma attending in the resuscitation room: does it affect outcome? Am Surg. 2001;67:611-614. 24. Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305-308. 25. McCabe C, Warren R. Trauma: an annotated bibliography of the literature: 2001. Am J Emerg Med. 2002;20:352-366. 26. Fulda GJ, Tinkoff GH, Giberson F, et al. In-house trauma surgeons do not decrease mortality in a level I trauma center. J Trauma. 2002;53:494-501. 27. Helling TS, Nelson PW, Shook JW, et al. The presence of in-house attending trauma surgeons does not improvement management or outcome of critically injured patients. J Trauma. 2003;55:2025. 28. Acierno SP, Jurkovich GJ, Nathens AB. Is pediatric trauma still a surgical disease? patterns of emergent operative intervention in the injured child. J Trauma. 2004;56:960-966. 29. Tepas JJ, Frykberg ER, Schinco MA, et al. Pediatric trauma is very much a surgical disease. Ann Surg. 2003;237:775-781. 30. Terregino CA, Reid JC, Marburger RK, et al. Secondary emergency department triage (supertriage) and trauma team activation: effects on resource utilization and patient care. J Trauma. 1997; 43:61-64. 31. Chen LE, Snyder AK, Minkes RK, et al. Trauma stat and trauma minor: are we making the call appropriately? Pediatr Emerg Care. 2004;20:421-425. 32. Simon B, Gabor R, Letourneau P. Secondary triage of the injured pediatric patient within the trauma center: support for a selective resource-sparing two-stage system. Pediatr Emerg Care. 2004; 20:5-11. 33. Tinkoff GH, O’Connor RE, Fulda GJ. Impact of a two-tiered trauma response in the emergency department: promoting efficient resource utilization. J Trauma. 1996;41:735-740. 34. Shatney CH, Sensaki K. Trauma team activation for “mechanism of injury” blunt trauma victims: time for a change? J Trauma. 1994;37:275-281. 35. Vernon DD, Bolte RG, Scaife E, et al. Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children’s hospital. Pediatr Emerg Care. 2005;21: 18-22.
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36. Plaisier BR, Meldon SW, Super DM, et al. Effectiveness of a 2specialty, 2-tiered triage and trauma team activation protocol. Ann Emerg Med. 1998;32:436-441. 37. Ochsner MG, Schmidt JA, Rozycki GS, et al. The evaluation of a two-tier trauma response system at a major trauma center: is it cost effective and safe? J Trauma. 1995;39:971-977. 38. Phillips JA, Buchman TG. Optimizing prehospital triage criteria for trauma team alerts. J Trauma. 1993;34:127-132. 39. DeKeyser FG, Paratore A, Seneca RP, et al. Decreasing the cost of trauma care: a system of secondary inhospital triage. Ann Emerg Med. 1994;23:841-844. 40. Eastes LS, Norton R, Brand D, et al. Outcomes of patients using a tiered trauma response protocol. J Trauma. 2001;50:908-913. 41. Dowd MD, McAneney C, Lacher M, et al. Maximizing the sensitivity and specificity of pediatric trauma team activation criteria. Acad Emerg Med. 2000;7:1119-1125. 42. Kohn MA, Hammel JM, Bretz SW, et al. Trauma team activation criteria as predictors of patient disposition from the emergency department. Acad Emerg Med. 2004;11:1-9. 43. Ciesla DJ, Moore EE, Moore JB, et al. Intubation alone does not mandate trauma surgeon presence on patient arrival to the emergency department. J Trauma. 2004;56:937-942. 44. Nathens AB, Brnet FP, Maier RV. Development of trauma systems and effect on outcomes after injury. Lancet. 2004;363:1794-1801.
45. Trauma Association of Canada. Accreditation guidelines. Available at: http://www.tac.medical.org. Accessed September 13, 2005. 46. Singh R, Kissoon N, Singh N, et al. Is a full team required for emergency management of pediatric trauma? J Trauma. 1992;33: 213-218. 47. Moore EE, Moore JB, Moore FA. The in-house trauma surgeon: paradigm or paradox. J Trauma. 1992;32:413-414. 48. Moore EE. Trauma systems, trauma centers, and trauma surgeons: opportunity in managed competition. J Trauma. 1995; 39:1-11. 49. Ciesla DJ, Moore EE, Moore JB, et al. The academic trauma center is a model for the future trauma and acute care surgeon. J Trauma. 2005;58:657-662. 50. American Association of Surgery for Trauma. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58: 614-616. 51. Maier RV. Trauma: the paradigm for medical care in the 21st century. J Trauma. 2003;54:803-813. 52. Cryer HM. The future of trauma care: at the crossroads. J Trauma. 2005;58:425-436. 53. Moore EE. Trauma surgery: is it time for a facelift? Ann Surg. 2004;240:563-564. 54. Green SM, Rothrock SG. Is pediatric trauma a surgical disease? Ann Emerg Med. 2002;39:537-540.
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Annals of Emergency Medicine 411
Is There Evidence to Support the Need for Routine Surgeon Presence on Trauma Patient Arrival? Steven M. Green, MD
From the Department of Emergency Medicine, Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA.
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. [Ann Emerg Med. 2006;47:405-411.] 0196-0644/$-see front matter Copyright © 2006 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2005.11.032
SEE RELATED EDITORIAL, P. 413. INTRODUCTION A central tenet of the American College of Surgeons’ (ACS) paradigm of trauma care is that “the general surgeon serves as the captain of the resuscitating team and is expected to be in the emergency department [ED] upon arrival of the seriously injured patient.”1 Indeed, compliance with this precept is mandated to obtain or maintain trauma center certification.1 Hospitals wishing such designations typically expend substantial resources to recruit and maintain a continuous call panel of surgeons capable of rapid ED response. The basis of this requisite is, of course, the inherent presumption that a surgeon awaiting the arrival of the patient improves trauma outcomes. Certainly there are patients for whom the earliest possible attendance by a surgeon can prove lifesaving; for example, those requiring emergency operative intervention for truncal penetrating trauma or persistent shock. However, in many settings such scenarios are increasingly unusual, and the specific incremental benefit of requiring a surgeon to be routinely present for each trauma team activation, rather than for just a well-defined subset of these patients, may be small relative to the substantial associated costs. Indeed, it would not Volume , . : May
appear to be efficient or professionally satisfying to require general surgeons to interrupt their other duties to attend patients unlikely to require their urgent intervention, such as those with isolated head or orthopedic injuries. In this article, I critically appraise this specific trauma center requirement in terms of its historical basis, its supporting evidence, its contrast with alternative systems outside of the United States, and its perception by trauma surgeons. I then discuss potential future changes to this requirement in the context of this background. This article is focused solely on the issue of mandatory surgeon presence on trauma patient arrival; it is presumed self evident that a single service skilled in definitive trauma management should oversee the postresuscitative evaluation and treatment for admitted patients. In preparing this article, I searched MEDLINE (through 2005 using search terms “attending trauma surgeon,” “trauma attending,” “in-house trauma,” and “secondary triage”), manually searched the tables of contents of the leading emergency medicine and surgery journals (1995 to 2005), and widely consulted emergency physician and surgical colleagues with special interest in trauma care. I searched the reference lists of all identified articles for additional relevant articles. Annals of Emergency Medicine 405
Routine Surgeon Presence on Trauma Patient Arrival
SCOPE OF THE REQUIREMENT The ACS stipulates that the presence of an attending general surgeon in the ED on patient arrival (presuming sufficient advance notification) is “essential” for all “major” resuscitations in trauma centers designated as Level I, II, or III.1 Hospitals may formulate their own criteria for surgeon involvement; however, at a minimum surgeons must be summoned for socalled major criteria: confirmed hypotension; respiratory compromise or intubation; gunshot wounds to the abdomen, neck, or chest; or a Glasgow Coma Scale score less than 8.2 In typical practice, most trauma centers activate teams for a far wider range of criteria than these, for philosophical, practical, and logistical considerations. Philosophically, there is a natural inclination of those writing the activation criteria to overtriage to minimize the prospect of missing serious injuries. Practically speaking, there is rarely time in most urban out-of-hospital systems for purported hypotension to be “confirmed” in the field, and if any doubt exists about the interpretation of activation guidelines, ED nurses communicating by radios are likely to be conservative and err on the side of activation. Logistically, trauma services are under ongoing pressure from hospital administrators to demonstrate that their patient care load is sufficient to warrant their existing level of resources, and the most straightforward way to increase volume is to expand activation criteria. Hospitals rarely object because the fees associated with trauma team activations are often substantial, and such revenue from insured patients helps offset corresponding losses for uninsured patients.3 The overall societal costs associated with such unduly generous use of trauma teams are enormous.
HISTORICAL BASIS AND EVOLUTION Before the late 1970s, most trauma victims were simply transported to the nearest ED regardless of the severity of their injuries or of the capabilities of the receiving hospital. As the ACS championed and promulgated the trauma center concept, they found 2 potent reasons to demand early surgeon involvement in trauma care. First, operative management was common. In that era, most patients with substantial blunt abdominal trauma routinely underwent diagnostic peritoneal lavage, which, if it yielded a positive result, mandated laparotomy. Surgeons regularly whisked injured victims to the operating room to explore abdomens and remove spleens within the then-touted “golden hour.”4 Second, surgeons were justifiably alarmed by the inconsistent trauma expertise of physicians staffing EDs in the late 1970s, primarily internists, family physicians, and residency dropouts. Indeed, the venerable Advanced Trauma Life Support course was inspired by an occurrence of “inadequate” care by such practitioners.5 The routine early involvement of surgeons was then viewed as essential to ensure that patients would be treated by practitioners competent in trauma care. A quarter century of medical evolution has fundamentally altered the landscape surrounding these 2 premises. Dramatic 406 Annals of Emergency Medicine
Green advances in the speed and resolution of computed tomography have largely obviated the need for “exploratory” surgery; indeed, even in the setting of radiographically documented intraabdominal injury most blunt trauma patients can now be safely treated nonoperatively.6-9 The practice of trauma surgery has transitioned from the invigoration of frequent “emergency” laparotomies to fairly routine and increasingly protocol-driven ward management.6,7,9-12 During this same quarter century, the specialty of emergency medicine has not just matured but also prospered. Emergency medicine residencies have been highly competitive for 2 decades. Most EDs serving trauma centers are now routinely staffed with emergency medicine residency graduates who are well trained and adept at trauma resuscitation and its associated procedures.
THE EVIDENCE Few researchers have focused their attention on the incremental value of having a surgeon routinely present during trauma resuscitations. Research that can be interpreted as bearing on this issue can be divided into between-hospital comparisons, within-hospital comparisons, retrospective assessment of surgeon involvement, and secondary triage schemes. A first caveat is that I discuss this research with a focus on patient-oriented rather than disease-oriented outcomes.13 The former refer to outcomes that matter to patients, which in the setting of trauma are primarily decreased mortality and morbidity. Disease-oriented outcomes, on the other hand, refer to intermediate or surrogate findings that may or may not translate into patient-oriented improvement. For example, some studies in this section report disease-oriented improvements (eg, faster time to the operating room, fewer errors in judgment) in the absence of patient-oriented improvement. Such findings are naturally less compelling than those that are patient-oriented. A second caveat is that I emphasize primary study objectives rather than secondary results reported from post hoc subset analyses. The latter are common in this set of literature, and their results are often strongly emphasized by their authors. However, it is well accepted that such post hoc comparisons are statistically prone to false-positive results and should be regarded with substantial skepticism.14,15 Finally, I do not discuss the research detailing decreases in trauma-related mortality over time, often concurrent with the implementation of specific trauma systems. Such research lacks the ability to isolate the incremental value of mandatory trauma surgeon presence. Potent confounding variables include the formalization of comprehensive trauma center resources (eg, specialist call, operating room mobilization, radiology and rehabilitation capabilities). Further, baseline mortality rates are known to be gradually improving over time because of improved traffic safety, decreased violent crime, and injury prevention initiatives.8,16,17 Volume , . : May
Green Between-Hospital Comparisons Three sets of investigators have compared trauma outcomes between hospitals using in-house surgeons and those permitting surgeons to take calls from home, based on the logical premise that the former group should be able to respond more quickly to trauma team activations and be more consistently present on patient arrival. In the first study, Rogers et al18 compared an urban hospital with in-house surgeons to a rural hospital in a different state with on-call surgeons. Overall mortality was similar between hospitals; however, more “errors in judgment” were noted at the rural hospital based on a nonblinded medical record review without explicit definitions. This study is confounded by the differences that would be expected between urban and rural locations in terms of patient population, out-of-hospital transport times, and the quantity and quality of supporting hospital resources. Demarest et al19 compared 2 tertiary trauma centers, one with in-house surgeons and one with out-of-hospital surgeons, and did not observe any differences in mortality or other outcomes. However, they report that their on-call surgeons (who all lived within 10 minutes) responded to the ED as quickly on average as the in-house group, and thus their results cannot address the issue of routine surgeon participation. The study of this format with the greatest relevance to the incremental value of surgeon presence is that of Khetarpal et al,20 who compared one hospital with in-house trauma attending physicians to another where surgeons were out-ofhospital and not typically involved until after the initial evaluation and resuscitation. They noted that the in-house group took their patients to the operating room more quickly than the on-call group for the subset of patients with penetrating trauma; however, there was no difference in overall mortality or other patient-oriented outcome to confirm any benefit from early surgeon involvement. A caveat about the above studies is that they compare only the role of trauma surgery attending physicians because in-house surgery residents were involved in patient care in both groups. Although the presence of residents might have diluted any adverse impact from the absence of attending surgeons, few would argue the suitability or advisability of substituting stafflevel clinical judgment for that of trainees.18,21 Indeed, the ACS no longer recognizes senior surgical residents as a substitute for surgical staff.1 Within-Hospital Comparisons Whether surgeons are in-house or taking calls from home varies in some trauma centers by the time of day or week or is left to the preference of each surgeon. Five investigators have compared trauma outcomes between periods of in-house versus out-of-hospital calls at single hospitals. Thompson et al22 compared trauma care provided during the daytime by in-house surgeons with care provided during evenings and nights when surgeons took calls from home. Mortality was similar between groups; however, their on-call Volume , . : May
Routine Surgeon Presence on Trauma Patient Arrival surgeons were able to respond to the ED as quickly as those in house, and thus the specific contribution of the surgeon themselves could not be isolated. Porter and Ursic23 describe their setting in which 6 of their 8 surgeons routinely took calls from outside the hospital and were not typically present at patient arrival. They reviewed trauma resuscitation flow sheets to divide their experience into patients for whom an attending surgeon was present during the resuscitation (23%) versus those in which this practice was not documented (77%). Although time to the operating room was faster with the in-house group, there were no overall differences in mortality, complications, or length of hospitalization. They report a nonsignificant trend toward fewer “missed” injuries and “inappropriate workup” in the surgeon-present group; however, they provide no explicit definitions for these subjective outcomes or other evidence that this retrospective judgment was performed in a manner likely to be free from bias.24 Although these authors conclude that in-house trauma surgeons are preferred, the ability of their data to support this assertion has been disputed.25 Fulda et al26 compared patients treated at their hospital by full-time faculty surgeons who took in-house calls with those treated by part-time community-practice surgeons who took calls from outside the hospital and were expected to be available within 30 minutes. They noted no difference in mortality (including the subset in which surgeon response was actually ⬎30 minutes), time to operating room, length of hospitalization, or other secondary outcomes. Helling et al27 compared patients treated at their hospital on weekends (when surgery attending physicians were usually in house) with those on nights and weekends (when they were usually out of the hospital but responded in an average of 16 minutes). They found no difference in mortality, complications, time to operating room, or hospital length of stay. ICU length of stay was longer in the in-house group. In the subset with penetrating injuries and shock, there were similarly no differences in mortality, time to the operating room, or other secondary outcomes. The research of this format with the greatest relevance to mandatory surgeon presence is that of Luchette et al,21 whose design was similar to the previous studies, except that their oncall surgeons did not routinely respond until after surgical resident evaluation of the patient. Although they report faster times to the operating room and to diagnostic testing for a subset of their sample (patients treated during the daytime but not during evenings or nights), there was no difference in mortality or ICU length of stay that might confirm any patientoriented benefit from early surgeon involvement. A limitation of the above research comparisons based on time of day or week is that, on average, less severely injured patients may be likely to present during routine weekday inhouse call hours. Further, a limitation of the comparisons based on surgeon preference is that the in-house surgeons are likely to be those more committed to trauma care. In both of these Annals of Emergency Medicine 407
Routine Surgeon Presence on Trauma Patient Arrival circumstances, these biases should create more favorable outcomes for the in-house group and thus exaggerate the apparent benefit of early surgeon involvement. Despite this inherent advantage, however, no such benefit was observed. All of the above studies have the same caveat about the presence of surgery residents mentioned in the last section. Retrospective Assessment of Surgeon Involvement Two sets of researchers have analyzed multicenter trauma registries to assess how frequently early surgeon involvement appeared to be valuable or necessary. In their analysis of 68,558 children (aged ⬍18 years) from the National Trauma Data Bank, Acierno et al28 found that 30.7% of patients ultimately underwent some type of operative procedure, of which the vast majority (89%) were orthopedic. The proportion of blunt trauma patients receiving emergency operative intervention (which they define as within 4 hours of ED arrival) by a general or pediatric surgeon was 3.6% for those aged 13 years or younger and was 5.6% for patients older than 13 years. The fraction of these patients needing such truly emergency interventions (eg, within 1 hour) is not specified, so it is difficult to speculate on what proportion of this sample may have directly benefited from routine surgeon presence on ED arrival. In a similar study, Tepas et al29 analyzed 87,424 cases from the National Pediatric Trauma Registry. They report that 11.4% of these children ultimately underwent some type of operative intervention and that 57.6% had at least 1 so-called surgical injury that they believe warranted evaluation by a surgeon of some specialty. The breakdown of how many of these operative procedures and surgical evaluations were emergency, urgent, or nonurgent is not specified, however, nor is the proportion performed by general or pediatric surgeons rather than orthopedists, neurosurgeons, or others. Thus, these data are also unable to quantify the unique contribution of a trauma surgeon early in each patient’s care. Secondary Triage Field triage criteria are used to determine which patients are transported to trauma centers. However, in many centers not all of these patients receive full trauma team activations with routine surgeon involvement. Instead, predefined criteria are used to “secondary triage” patients into multiple tiers of response. Secondary triage techniques do not divert patients away from trauma centers but rather serve as a mechanism for focusing surgeon attention on those cases most likely to require their unique skills. There are numerous reports of various systems of secondary triage, with lower-risk patients either forgoing surgeon involvement altogether unless requested by the emergency physician30-35 or delaying such consultation until the postresuscitation phase, when time permits.36 These studies have uniformly suggested that such techniques appear accurate and safe while permitting 36% to 72% of patients to avoid needless trauma team activation.30,32,33,35-38 Secondary triage 408 Annals of Emergency Medicine
Green has been shown to decrease ED length of stay33 and to be cost efficient and resource efficient.30,31,33-40 Most of these secondary triage schemes retain physiologic and core anatomic triage criteria (ie, those considered by the ACS to constitute “major” resuscitations2) to activate trauma teams but defer such activations for other low-yield criteria such as mechanism of injury.34,41,42 However, Ciesla et al43 instituted a secondary triage policy deferring surgeon involvement for 1 ACS major resuscitation criterion: respiratory compromise or intubation. Of 489 such patients, just 22 (4%) patients received emergency operative intervention by a trauma surgeon, with 12 of these 22 cases being stab wounds. These authors conclude that after exclusion of stab wounds, field or ED intubation alone rarely leads to emergency surgeon intervention and that “the decision to have the trauma surgeon present upon the patient’s arrival is better made by trained emergency department physicians than a blanket requirement for all intubated patients regardless of physiology.”43
SETTINGS OUTSIDE OF THE UNITED STATES Despite the influence of the ACS on trauma care worldwide, the concept of routine surgeon presence on patient arrival has not been widely accepted outside of the United States. Indeed, in most European countries trauma resuscitations are routinely managed by nonsurgical critical care physicians, and there is no compelling evidence to support any presumed superiority of the American model.44 Nathens et al44 contrast the American and French systems of trauma care and note that, despite higher French motor vehicle fatality rates, there are potent confounding variables that hinder any reliable comparison of quality of care. Canadian trauma center criteria have never mandated routine trauma surgeon presence but instead permit emergency physicians to consult these specialists on an as-needed basis.45 Singh et al46 describe a Canadian system of pediatric trauma care in which patients are treated by emergency physicians with backup by a pediatric intensivist physician available within 5 minutes. Surgeons are not routinely involved but are instead consulted based on the emergency physician evaluation. They report similar morbidity and mortality at American centers.46
TRAUMA SURGEON PERSPECTIVE Modern trauma surgeons are now less tolerant about lifestyle issues.3,7,11,12,47-49 They work “unappealing hours, with a great deal of unpredictability, high stakes and high stress.”50 Ciesla et al43 recently wrote: “As the criteria for major resuscitation are broadened, we spend proportionately more time evaluating patients that could be initially managed by ED physicians trained in trauma care in conjunction with neurosurgeons and orthopedic surgeons. This should not be considered abdication of trauma care to the ED physician but a more appropriate distribution of priorities to qualified personnel.” They continue: “. . .we continue self-imposed mandates that only serve to make our environment less Volume , . : May
Green desirable. In effect, we have become our own worst enemies.” Maier51 echoes this: “. . . our research demonstrates no improvement in patient care by mandating in-house attending trauma coverage. Why do we mandate onerous standards without evidence to support them? To prove how much we can sacrifice?” Similarly, Cryer52 notes that “In point of fact very few patients require the immediate presence of a general surgeon. Well-trained ED physicians are capable of initiating the care of the vast majority of patients.” Further, rapid surgeon response in many settings requires a doubling at minimum of the number of general surgeons on the call roster.47,48 In larger academic centers, this frequently necessitates recruiting general surgeons specialized in areas other than trauma. The resulting “paradox” is that this requirement can lead to more trauma care being delivered by surgeons with limited related interest and experience.47,48 Trauma surgeons are attempting a “facelift” of their subspecialty by reestablishing challenging operative components (eg, vascular, thoracic) to their practice.48,50,53
IMPLICATIONS Given the above background, the premise that trauma outcomes are improved by the routine presence of surgeons on patient arrival must be considered an unproven hypothesis. The 2 historical factors that originally prompted this requirement—frequent exploratory laparotomies and EDs staffed by physicians without trauma training—are no longer realities in most modern trauma centers. Research from multiple centers and in multiple varying formats has repeatedly failed to identify improvement in patient-oriented outcomes from early surgeon involvement. European and Canadian trauma care do not routinely involve surgeons in the resuscitation phase, without any demonstrated or perceived decrease in 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. So given the lack of a compelling basis, why does the routine early arrival of a surgeon remain an ACS certification requirement? The first reason may be that open questioning of this longstanding tradition by surgeons43,51 and emergency physicians46,54 is only a recent phenomenon and that more open debate will be required for all viewpoints to be heard and considered. Second, and more potent, many surgeons likely feel a visceral passion and sense of ownership over trauma care that may be difficult to reconcile with evidence-based medicine. Surgeons indeed deserve immense and complete credit for organizing and implementing our now-precious network of trauma centers, and any action that might scale back their historical routine presence on patient arrival may threaten or symbolize a loss of control or ultimate authority over the process. However, it should not be perceived as a personal affront to trauma surgeons that their Volume , . : May
Routine Surgeon Presence on Trauma Patient Arrival dramatic success in maturing their subspecialty has rendered them less essential minute by minute.
THE FUTURE Given the lack of evidentiary support for the routine presence of surgeons at trauma activations, there would not appear to be an objective reason to retain this certification requirement. Removing or modifying this mandate would provide trauma centers the flexibility they now lack to individualize their secondary triage criteria based on unique local resources, expertise, and caseload distributions. Research resulting from innovative secondary triage strategies will better clarify which trauma patients require either emergency or urgent unique expertise of a general surgeon during the initial phase of trauma management. Should this stipulation be relaxed, it is unlikely that many urban trauma centers would discontinue routine surgeon involvement for trauma victims with truncal penetrating injury or persistent shock. However, factors such as respiratory compromise and intubation or Glasgow Coma Scale score less than 8 in the absence of other major criteria suggest primarily head injury, a situation unlikely to be associated with emergency operative intervention by a general surgeon. Rather than routinely interrupting their other duties to be present on the arrival of such patients, surgeons could instead evaluate this subset in delayed fashion when time permits unless summoned more quickly by the treating emergency physician. The important caveat of any such secondary triage criteria modifications would be that the involved emergency physicians must be willing and able to effectively take up any newly created slack. Despite the near-complete maturation of emergency medicine as a specialty, in some trauma centers the situation may not yet be right for such a change. However, many other such institutions are already staffed with residency-trained emergency physicians with demonstrated competence at trauma resuscitation and its related procedures. Such ED staff are likely to exhibit an ongoing commitment to superior trauma care and the willingness to actively participate in continuous quality improvement. In such centers, surgeons and emergency physicians can likely refine their secondary triage criteria together in a collegial manner that ensures high-quality care but yet more efficiently uses surgeons’ time. An outstanding example of such collaboration has been described by Ciesla et al.43
CONCLUSION The premise that trauma outcomes are improved by the routine presence of surgeons on patient arrival lacks an objective evidentiary basis, despite being an ACS trauma center certification requirement. Future 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 Annals of Emergency Medicine 409
Routine Surgeon Presence on Trauma Patient Arrival permitted the flexibility necessary to perform such research and to use such findings to refine and focus their secondary triage criteria. Supervising editor: Judd E. Hollander, MD Funding and support: The author reports this study did not receive any outside funding or support. Publication dates: Received for publication September 14, 2005. Revision received November 18, 2005. Accepted for publication November 21, 2005. Available online January 18, 2006. Reprints not available from the author. Address for correspondence: Steven M. Green, MD, Loma Linda University Medical Center A-108, 11234 Anderson Street, Loma Linda, CA 92354; 909-558-4085; fax 775-3074121; E-mail [email protected]. REFERENCES 1. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 1999. 2. American College of Surgeons Committee on Trauma. Amendments to Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2000. 3. Rodriguez JL, Christma AB, Franklin GA, et al. Trauma/critical care surgeon: a specialist gasping for air. J Trauma. 2005;59:1-7. 4. Lerner EB, Moscati RM. The golden hour: scientific fact or medical “urban legend”? Acad Emerg Med. 2001;8:758-760. 5. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Manual. 7th ed. Chicago, IL: American College of Surgeons; 2004. 6. Eastern Association for the Surgery of Trauma. EAST ad hoc committee for the development of practice management guidelines: trauma practice guidelines Eastern Association for the Surgery of Trauma. Available at: http:// www.east.org. Accessed September 13, 2005. 7. Richardson JD, Miller FB. Will future surgeons be interested in trauma care? results of a resident survey. J Trauma. 1992;32: 229-233. 8. Engelhardt S, Hoyt D, Coimbra R, et al. The 15-year evolution of an urban trauma center: what does the future hold for the trauma surgeon? J Trauma. 2001;51:633-638. 9. Fakhry SM, Watts DD, Michetti C, et al. The resident experience on trauma: declining surgical opportunities and career incentives? analysis of data from a large multi-institutional study. J Trauma. 2003;54:1-8. 10. Flint LM. Discussion regarding “pediatric trauma is very much a surgical disease.” Ann Surg. 2003;237:780. 11. Richardson JD. Trauma centers and trauma surgeons: have we become too specialized? J Trauma. 2000;48:1-7. 12. Richardson JD. Is there an ideal model for training the trauma surgeons of the future? J Trauma. 2003;54:795-797. 13. Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract. 2004; 17:59-67. 14. Rothwell PM. Subgroup analysis in randomized controlled trials: importance, indications, and interpretation. Lancet. 2005;365: 176-186. 15. Oxman AD, Guyatt GH. A consumer’s guide to subgroup analyses. Ann Intern Med. 1992;116:78-84.
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Green 16. Hulka F, Mullins RJ, Mann NC, et al. Influence of a statewide trauma system on pediatric hospitalization and outcome. J Trauma. 1997;42:514-519. 17. Biffl WL, Harriington DT, Majercik SD, et al. The evolution of trauma care at a level I trauma center. J Am Coll Surg. 2005; 200:922-929. 18. Rogers FB, Simons R, Hoyt DB, et al. In-house board-certified surgeons improve outcome for severely injured patients: a comparison of two university centers. J Trauma. 1993;34:871875. 19. Demarest GB, Scannell G, Sanchez K, et al. In-house versus on-call attending trauma surgeons at comparable level I trauma centers: a prospective study. J Trauma. 1999;46:535540. 20. Khetarpal S, Steinbrunn BS, McGonigal MD, et al. Trauma faculty and trauma team activation: impact on trauma system function and patient outcome. J Trauma. 1999;47:576-581. 21. Luchette F, Kelly B, Davis K, et al. Impact of the in-house trauma surgeon on initial patient care, outcome, and cost. J Trauma. 1997;42:490-495. 22. Thompson CT, Bickell WH, Siemens RA, et al. Community hospital level II trauma center outcome. J Trauma. 1992;32:336341. 23. Porter JM, Ursic C. Trauma attending in the resuscitation room: does it affect outcome? Am Surg. 2001;67:611-614. 24. Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305-308. 25. McCabe C, Warren R. Trauma: an annotated bibliography of the literature: 2001. Am J Emerg Med. 2002;20:352-366. 26. Fulda GJ, Tinkoff GH, Giberson F, et al. In-house trauma surgeons do not decrease mortality in a level I trauma center. J Trauma. 2002;53:494-501. 27. Helling TS, Nelson PW, Shook JW, et al. The presence of in-house attending trauma surgeons does not improvement management or outcome of critically injured patients. J Trauma. 2003;55:2025. 28. Acierno SP, Jurkovich GJ, Nathens AB. Is pediatric trauma still a surgical disease? patterns of emergent operative intervention in the injured child. J Trauma. 2004;56:960-966. 29. Tepas JJ, Frykberg ER, Schinco MA, et al. Pediatric trauma is very much a surgical disease. Ann Surg. 2003;237:775-781. 30. Terregino CA, Reid JC, Marburger RK, et al. Secondary emergency department triage (supertriage) and trauma team activation: effects on resource utilization and patient care. J Trauma. 1997; 43:61-64. 31. Chen LE, Snyder AK, Minkes RK, et al. Trauma stat and trauma minor: are we making the call appropriately? Pediatr Emerg Care. 2004;20:421-425. 32. Simon B, Gabor R, Letourneau P. Secondary triage of the injured pediatric patient within the trauma center: support for a selective resource-sparing two-stage system. Pediatr Emerg Care. 2004; 20:5-11. 33. Tinkoff GH, O’Connor RE, Fulda GJ. Impact of a two-tiered trauma response in the emergency department: promoting efficient resource utilization. J Trauma. 1996;41:735-740. 34. Shatney CH, Sensaki K. Trauma team activation for “mechanism of injury” blunt trauma victims: time for a change? J Trauma. 1994;37:275-281. 35. Vernon DD, Bolte RG, Scaife E, et al. Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children’s hospital. Pediatr Emerg Care. 2005;21: 18-22.
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36. Plaisier BR, Meldon SW, Super DM, et al. Effectiveness of a 2specialty, 2-tiered triage and trauma team activation protocol. Ann Emerg Med. 1998;32:436-441. 37. Ochsner MG, Schmidt JA, Rozycki GS, et al. The evaluation of a two-tier trauma response system at a major trauma center: is it cost effective and safe? J Trauma. 1995;39:971-977. 38. Phillips JA, Buchman TG. Optimizing prehospital triage criteria for trauma team alerts. J Trauma. 1993;34:127-132. 39. DeKeyser FG, Paratore A, Seneca RP, et al. Decreasing the cost of trauma care: a system of secondary inhospital triage. Ann Emerg Med. 1994;23:841-844. 40. Eastes LS, Norton R, Brand D, et al. Outcomes of patients using a tiered trauma response protocol. J Trauma. 2001;50:908-913. 41. Dowd MD, McAneney C, Lacher M, et al. Maximizing the sensitivity and specificity of pediatric trauma team activation criteria. Acad Emerg Med. 2000;7:1119-1125. 42. Kohn MA, Hammel JM, Bretz SW, et al. Trauma team activation criteria as predictors of patient disposition from the emergency department. Acad Emerg Med. 2004;11:1-9. 43. Ciesla DJ, Moore EE, Moore JB, et al. Intubation alone does not mandate trauma surgeon presence on patient arrival to the emergency department. J Trauma. 2004;56:937-942. 44. Nathens AB, Brnet FP, Maier RV. Development of trauma systems and effect on outcomes after injury. Lancet. 2004;363:1794-1801.
45. Trauma Association of Canada. Accreditation guidelines. Available at: http://www.tac.medical.org. Accessed September 13, 2005. 46. Singh R, Kissoon N, Singh N, et al. Is a full team required for emergency management of pediatric trauma? J Trauma. 1992;33: 213-218. 47. Moore EE, Moore JB, Moore FA. The in-house trauma surgeon: paradigm or paradox. J Trauma. 1992;32:413-414. 48. Moore EE. Trauma systems, trauma centers, and trauma surgeons: opportunity in managed competition. J Trauma. 1995; 39:1-11. 49. Ciesla DJ, Moore EE, Moore JB, et al. The academic trauma center is a model for the future trauma and acute care surgeon. J Trauma. 2005;58:657-662. 50. American Association of Surgery for Trauma. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58: 614-616. 51. Maier RV. Trauma: the paradigm for medical care in the 21st century. J Trauma. 2003;54:803-813. 52. Cryer HM. The future of trauma care: at the crossroads. J Trauma. 2005;58:425-436. 53. Moore EE. Trauma surgery: is it time for a facelift? Ann Surg. 2004;240:563-564. 54. Green SM, Rothrock SG. Is pediatric trauma a surgical disease? Ann Emerg Med. 2002;39:537-540.
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