Trauma Directors Research Articles

The Peacetime Trauma Experience of U.S. Army Surgeons: Another Call for Collaborative Training in Civilian Trauma Centers

To document the ongoing trauma experience of U.S. Army surgeons during peacetime clinical practice. Surveys were mailed to the trauma directors of military surgical services worldwide. Questions focused on numbers of operative cases and availability of trauma resources. Laparotomy, thoracotomy, and vascular repair for trauma were considered index cases and simple means were computed based on numbers of cases per general surgeon. Seventy percent of worldwide Army surgical services responded to the survey. In 1992, on the average, a general surgeon in the Army performed 1.3 trauma laparotomies, 0.3 thoracotomies, and 0.3 vascular repairs for trauma. Only 6 of 28 surgical services had an organized "trauma team," 3 held regular trauma conferences, and 1 service kept a registry and could calculate an average injury severity score. Our data support perceptions concerning lack of an ongoing trauma experience for military surgeons and reinforces the need for collaborative education and training in busy civilian trauma centers. A regional approach is suggested as a viable solution.

Analysis of American College of Surgeons trauma consultation program.

To identify the criteria deficiencies found during peer consultation of hospitals and the relationship to subsequent verification. Between September 1987 and December 1992, 52 hospitals had consultation visits using American College of Surgeons criteria. Each report was studied for deficiencies, frequency of deficiencies, and relationship to verification. There are 108 American College of Surgeons criteria. Thirty-five different criteria deficiencies were found. The number of deficiencies per hospital ranged from zero to 12. The more frequent deficiencies included a lack of the following: quality improvement, 35 (67%); trauma service, 20 (38%); trauma surgeon in emergency department, 20 (38%); 24-hour operating room availability, 17 (33%); trauma registry, 17 (33%); trauma continuing medical education, 16 (31%); trauma director, 15 (29%); computed tomography technician in hospital, 15 (29%); research, 14 (27%); trauma coordinator, 14 (27%); and neurosurgeon availability, 13 (25%). No hospital that lacked commitment of surgeons (n = 12) or hospital (n = 3) requested a verification visit. Twenty-four hospitals (46%) achieved verification by February 1994. Twenty-eight hospitals had six or fewer deficiencies, with 19 (68%) verified. Twenty-four hospitals had seven or more deficiencies, with only five (21%) subsequently verified. Verification visits followed consultation by 3 to 52 months. Two hospitals with nine deficiencies were verified after 30 and 48 months, although one failed its first verification visit. American College of Surgeons consultation assists hospitals to identify their trauma center capability and appears to improve their ability to pass subsequent trauma center verification. Most criteria deficiencies are correctable. Lack of commitment by the surgeons or hospital is difficult to correct. There is an inverse relationship between the number of deficiencies and subsequent verification.

Clinical Medicine Meets Forensic Sciences

LIKE A SLEUTH tracking an elusive killer, Charles Buerk, MD, still questions the death 2 years ago of a 39-year-old stabbing victim. The injury wasn't serious—a mild puncture wound in the left flank. But the victim died unexpectedly in the hospital 2 days later from adult respiratory distress syndrome (ARDS). Buerk, a trauma surgeon and director of surgical education at Orlando (Fla) Regional Medical Center, presented the case and several others at the annual meeting of the American Academy of Forensic Sciences in San Antonio, Tex. They illustrate how clinicians and medical examiners are collaborating to enhance quality assurance and ultimately improve patient care. Buerk recounted clues in the unexplained ARDS death. When the patient arrived at the emergency department within an hour after the stabbing, he was stable, alert, and oriented but his white blood cell count on admission was 30.0×10 9 /L. During repair of a small serosal

Trauma Nurse Coordinator

Three nursing positions were created to effectively manage the Trauma Nurse Coordinator (TNC) role and responsibilities: Trauma Director, Clinical Nurse Specialist and Trauma Researcher. By using this innovative approach, the quality of trauma care improved as shown by decreased complication rates, lengths of stay, and trauma costs. In addition, trauma referrals, research and education increased.

CHARACTERISTICS OF TRAUMA CENTERS AND TRAUMA SURGEONS

We surveyed directors of trauma at 408 trauma centers (as indicated by the state chairmen of the American College of Surgeons' Committee on Trauma [ACSCOT]). Of the 408 trauma directors 290 (71%) responded with information relative to their hospitals and the 1537 general surgeons taking trauma call. Altogether, 75% of the surgeons worked on an identified trauma service, 80% belonged to a cadre of surgeons identified as expert, 52% were viewed as full time, 25% provided in-house staff coverage, and 76% had completed an ATLS course. Six percent of the entire group were 60 to 73 years old and demonstrated a commitment to trauma equal to that of their younger cohorts. As a group, the older surgeons took less call, but when community or the institutional call needs were identified, the older surgeons met the challenge.

Cost Effectiveness of Trauma Quality Assurance Audit Filters

The American College of Surgeons Committee on Trauma (ACSCOT) has published recommended minimal audit filters for trauma quality assurance. In this study ten filters were assessed through variable sample sizes over a 1-year period for cost and efficiency. Each filtered case was screened by trauma nurse coordinators. The trauma director reviewed possible deviations from standard and presented cases at peer review conferences for consensus on problem identification. While several filters had reasonable yield, most filters had minimal or no yield. Ten de novo problems were identified at a cost of +1,000 per de novo problem. Six filters were modified based on common reasons for overfiltration, resulting in a substantial reduction in filtration rate without losing problem identification. We conclude that ACSCOT audit filters 1 (unexpected deaths), 4 (ICU LOS greater than twice the average), 5 (trauma surgeon response), and 9 (major surgery greater than 24 hours) have a reasonable yield. Filters 2, 3, 7, 8, 11, and 12 have limited value to an established suburban trauma center and are not cost effective. Modifications of these filters can reduce cost without obvious impact on effectiveness. Specific audit filters recommended for future study are presented.