In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis

Abstract

BACKGROUND:A rapid trauma response is essential to provide optimal care for severely injured patients. However, it is currently unclear if the presence of an in-house trauma surgeon affects this response during call and influences outcomes. This study compares in-hospital mortality and process-related outcomes of trauma patients treated by a 24/7 in-house versus an on-call trauma surgeon. METHODS:PubMed/Medline, Embase, and CENTRAL databases were searched on the first of November 2020. All studies comparing patients treated by a 24/7 in-house versus an on-call trauma surgeon were considered eligible for inclusion. A meta-analysis of mortality rates including all severely injured patients (i.e., Injury Severity Score of ≥16) was performed. Random-effect models were used to pool mortality rates, reported as risk ratios. The main outcome measure was in-hospital mortality. Process-related outcomes were chosen as secondary outcome measures. RESULTS:In total, 16 observational studies, combining 64,337 trauma patients, were included. The meta-analysis included 8 studies, comprising 7,490 severely injured patients. A significant reduction in mortality rate was found in patients treated in the 24/7 in-house trauma surgeon group compared with patients treated in the on-call trauma surgeon group (risk ratio, 0.86; 95% confidence interval, 0.78-0.95; p = 0.002; I 2 = 0%). In 10 of 16 studies, at least 1 process-related outcome improved after the in-house trauma surgeon policy was implemented. CONCLUSION:A 24/7 in-house trauma surgeon policy is associated with reduced mortality rates for severely injured patients treated at level I trauma centers. In addition, presence of an in-house trauma surgeon during call may improve process-related outcomes. This review recommends implementation of a 24/7 in-house attending trauma surgeon at level I trauma centers. However, the final decision on attendance policy might depend on center and region-specific conditions.

The effect of an on-site trauma surgeon during resuscitations of severely injured patients

“…(median 2.7 h (IQR 1.6-4.0) vs 2.1 h (1.5-3.7) p < 0.01) There was also a significant decrease in time from the ED (Emergency Department) to the intensive care unit (ICU) for patients directly transferred to the ICU (median time of 1.4 h (IQR 1.1-2.5) vs 1.2 h (IQR 1.0-1.6) (p < 0.01) and almost doubling of the percentage of patients who reached the operation room within 30 minutes (4.8% vs 8.0%) [14]. Moreover, a recent systematic of de la Mar et al, [15] revealed that ten out of sixteen included studies found at least one process related outcome to be improved after the implementing an in-house trauma surgeon attendance strategy. Furthermore, 7490 severely injured patients were included in a meta-analysis from eight different studies and severely injured patients treated by on-site surgeons had a significantly lower mortality rate when compared to trauma surgeons on call (risk ratio 0.86, 95% confidence interval 0.78 to 0.95; P < 0.01).…”

Future perspectives of higher standards for trauma teams' organization, support, and evaluation

“…Besides the benefits, an experienced trauma team leader brings during the trauma resuscitation, their additional experience for managing the severely injured may also have beneficial implications for the process after the resuscitation in the trauma bay, such as time to the operation room or additional imaging. For the management pace of severely injured patients, a recent systematic review showed that ten out of sixteen included studies found at least one process-related outcome was improved after implementing an in-house attendance policy for trauma surgeons instead of the on-call attendance policy during which less experienced surgical residents act as the house officer [ 23 ].…”

Outcome of severely injured patients in a unique trauma system with 24/7 double trauma surgeon on-call service

“…Some authors did not demonstrate any reduction on mortality [ 1 , 2 ], whereas others provided arguments for a decrease in preventable deaths [ 3 ]. A recent review on this topic suggested that a 24/7 in-house trauma surgeon was associated with reduced mortality for severely injured patients in a level-1 trauma center setting [ 5 ].…”