The Dedicated Trauma Surgeon: A Retrospective Review on Patient Outcomes

Transcription

1 The Dedicated Trauma Surgeon: A Retrospective Review on Patient Outcomes Truong D. Ma, MD, MS;Tiffany D. Marchand, MD; M. D. Gothard, MS; Karen M. Gil, PhD; Richard L. George, MD, MSPH

2 We have no disclosures

3 Introduction Dedicated intensivist improves outcomes in the MICU Leapfrog encourages 24/7 intensivist model of ICU care Problematic implementation for trauma surgeon/intensivist Revised staffing model at our institution in 2012 Our Goal: Determine if the presence of a dedicated trauma surgeon at daily ICU trauma rounds resulted in improved patient outcomes compared to the classic general surgery model of trauma care.

4 2010 General Surgery Model Research General Surgery Inpatients Trauma Surgery Trauma Inpatients Surgeon Clinic Responsibilities Elective Surgery Trauma ICU Trauma Evals or Activations General Surgery ICU Emergent Surgery 4

5 2012 Dedicated Trauma Surgeon Model Trauma Inpatients Trauma ICU Surgeon Trauma Surgery Trauma Evals or Activations 5

6 Methods Retrospective data from a single Northeast Ohio Level I Trauma Center comparing two 1-year periods Descriptive demographics Injury severity scores (ISS) stratified into 4 groups: minor (1), moderate (2), severe (3), very severe (4) Outcomes Pearson Chi square test Mann Whitney U test

7 Results A total of 2,681 patients reviewed from 2010 and ICU days < 24 hours (1,390 patients) and no injury severity scores (16 patients) excluded. 1,275 patients with an ICU stay 24 hours were included

8 Table 1: Characteristics Study Period P-value 2010 (n=589) 2012 (n=686) ISS Group n (%) (46.3%) 294 (42.9%) (28.7%) 218 (31.8%) 3 92 (15.6%) 109 (15.9%) 4 55 (9.3%) 65 (9.5%) Injury Type n (%) Minor Fall 256 (43.5%) 321 (46.8%) MVC 138 (23.4%) 165 (24.1%) MCC 42 (7.1%) 41 (6.0%) Assault 28 (4.8%) 43 (6.3%)

9 Table 2: Outcomes Study Period 2010 (n=589) 2012 (n=686) P-value Mortality n (%) 47 (8.0%) 61 (8.9%) Length of ICU Stay- mean days (SD) 5.8 (7.26) 3.9 (5.12) <0.001 # Mechanically Ventilated - n (%) 192 (32.6%) 181 (26.4%) Days on Ventilator mean (SD) 9.6 (8.97) 6.3 (6.69) <0.001 Patients released to Floor n (%) 314 (53.3%) 476 (69.4%) <0.001 Patients receiving Palliative care n (%) 29 (4.9%) 26 (3.8%) Patients with DVT - n (%) 62 (10.5%) 77 (11.2%) Patients receiving blood - n (%) 202 (34.3%) 112 (16.3%) <0.001 Charges mean (SD) $130, (140,753.68) $116, (117,774.62) 0.873

10 Discussion Limitation: Ventilator reduction protocol completed October 2011 Studies show up to 25% reduction in ventilation days with ventilator reduction protocols 33% reduction in our study Attending availability for extubation likely a factor Does not explain decrease in number ventilated

11 Discussion Blood product use had greatest effect with a decrease of 50% Other studies showed reduced: blood products, imaging, cost and resource utilization Possible charge savings with a larger powered study Implementation with other trauma surgeons and trauma centers

12 Summary A dedicated trauma surgeon rounding on patients is associated with: A decrease in mechanical ventilation days and usage. A decrease in blood products transfused A decrease in ICU days And an increase in floor transfers without a statistically significant difference in mortality rates This could translate to more efficient and costeffective care.

13 References 1. Roettger RH, Taylor SM, Youkey JR, Blackhurst DW. The general surgery model: a more appealing and sustainable alternative for the care of trauma patients. Am Surg Aug;71(8):633-8; discussion Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA Nov 6;288(17): Nathens AB, Rivara FP, MacKenzie EJ, et al. The impact of an intensivist-model ICU on trauma-related mortality. Ann Surg Oct;244(4): Petitti D, Bennett V, Chao Hu CK. Association of changes in the use of board-certified critical care intensivists with mortality outcomes for trauma patients at a well-established level I urban trauma center. J Trauma Manag Outcomes Mar 6;6:3. 5. Checkley W, Martin GS, Brown SM, et al, United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study Investigators. Structure, process, and annual ICU mortality across 69 centers: United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Crit Care Med Feb;42(2): Lee J, Rogers F, Rogers A, Horst M, Chandler R, Miller JA. Mature trauma intensivist model improves intensive care unit efficiency but not mortality. J Intensive Care Med Mar;30(3): National Trauma Database Van der Wilden GM, Schmidt U, Chang Y, Bittner EA, Cobb JP, Velmahos GC, Alam HB, de Moya MA, King DR. Implementation of 24/7 intensivist presence in the SICU: effect on processes of care. J Trauma Acute Care Surg Feb;74(2): Hanson CW 3rd, Deutschman CS, Anderson HL 3rd, Reilly PM, Behringer EC, Schwab CW, Price J. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med Feb;27(2):270-4.

14 Thank You