In-House Board-Certified Surgeons Improve Outcome for Severely Injured Patients

Fb, Rogers; Simons, R.; Db, Hoyt; Shackford,; Holbrook, Troy L.; Fortlage, Dale

doi:10.1097/00005373-199306000-00019

Cited by 49 publications

(38 citation statements)

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“…Studies from intensive care units support such an interpretation. Increased mortality during off-hours in the case of non-24-hour availability of intensivists has been reported, 28 and the introduction of 24-hour availability of senior intensivists was associated with decreased intensive care unit complication rates, hospital length of stay 29,30 and no differences in mortality between day, evening or night-time. 31,32 The same results were found in paediatric intensive care units 33 and maternity units.…”

Section: Discussionmentioning

confidence: 98%

Increased adverse perinatal outcome of hospital delivery at night

Graaf

Ravelli

Visser

et al. 2010

BJOG

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Objective To determine whether delivery in the evening or at night and some organisational features of maternity units are related to perinatal adverse outcome.Design A 7-year national registry-based cohort study.Setting All 99 Dutch hospitals.Population From nontertiary hospitals (n = 88), 655 961 singleton deliveries from 32 gestational weeks onwards, and, from tertiary centres (n = 10), 108 445 singleton deliveries from 22 gestational weeks onwards.Methods Multiple logistic regression analysis of national perinatal registration data over the period 2000-2006. In addition, multilevel analysis was applied to investigate whether the effects of time of delivery and other variables systematically vary across different hospitals.Main outcome measures Delivery-related perinatal mortality (intrapartum or early neonatal mortality) and combined delivery-related perinatal adverse outcome (any of the following: intrapartum or early neonatal mortality, 5-minute Apgar score below 7, or admission to neonatal intensive care).Results After case mix adjustment, relative to daytime, increased perinatal mortality was found in nontertiary hospitals during the evening (OR, 1.32; 95% CI, 1.15-1.52) and at night (OR, 1.47; 95% CI, 1.28-1.69) and, in tertiary centres, at night only (OR, 1.20; 95% CI, 1.06-1.37). Similar significant effects were observed using the combined perinatal adverse outcome measure. Multilevel analysis was unsuccessful; extending the initial analysis with nominal hospital effects and hospital-delivery time interaction effects confirmed the significant effect of night in nontertiary hospitals, whereas other organisational effects (nontertiary, tertiary) were taken up by the hospital terms.Conclusion Hospital deliveries at night are associated with increased perinatal mortality and adverse perinatal outcome. The time of delivery and other organisational features representing experience (seniority of staff, volume) explain hospital-to-hospital variation.Keywords Adverse perinatal outcome, early neonatal mortality, intrapartum mortality, organisation of maternity units, seniority of staff, timing of hospital delivery, volume of deliveries.

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Section: Discussionmentioning

confidence: 98%

Increased adverse perinatal outcome of hospital delivery at night

Graaf

Ravelli

Visser

et al. 2010

BJOG

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“…Specifically, there have been conflicting reports on the effect of initiating a 24-hour in-house presence of trauma attending physicians. Some have suggested improved outcomes, [1][2][3] others have demonstrated no difference, [4][5][6][7] and still others have suggested that the question be posed in a different way. 8 Advances in trauma care have made mortality progressively less common among critically injured patients surviving to leave the emergency department (ED).…”

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confidence: 99%

Enhanced trauma program commitment at a level i trauma center

Cornwell¹

2003

Arch Surg

103

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Hypothesis: With advances in surgical care, the occurrences of major adverse outcomes have become a rare event. The effect of a surgical service can be more comprehensively evaluated by following the Donabedian model, looking at the triad of structure, process, and outcome. It is hypothesized that the implementation of a focused program commitment at a trauma center is associated with improvements in process of care and patient outcomes.Design: Evaluation of prospectively collected information in a trauma registry for the 3-year periods immediately before (1995-1997) and after (1999-2001) the implementation (in 1998) of the full-time trauma service.Setting: Level I university-affiliated trauma center.Patients: Patients meeting criteria for major trauma. Intervention:The implementation of a full-time trauma service, featuring 24-hour in-house attending coverage, dedicated trauma admitting unit, regular trauma core curriculum, regular multidisciplinary quality assurance meetings, and state designation for level I status.Main Outcome Measures: Process of care measures, including time in the emergency department (ED) and trauma "bypass" hours (ie, time spent in the trauma resuscitation area). Outcome measures, including lengths of stay, overall mortality and mortality, excluding ED deaths.Results: The total number of patients with major trauma increased from 2240 (1995)(1996)(1997) to 2513 (1999-2001). The average time in the ED for patients going to the operating room, intensive care unit, and observation wards all decreased significantly (84 vs 52 minutes, 197 vs 118 minutes, and 300 vs 140 minutes, respectively; all with PϽ.01). The number of hours that the trauma center was closed owing to ED overcrowding also decreased significantly, from 56 to 2.7 hours per month (PϽ.01). After excluding ED deaths, there was a trend on bivariate analyses toward lower overall mortality rates (4.5% vs 3.4%, P=.07) and mortality rates among patients with severe head injury (23.8% vs 17.2%, P =.07). On further analyses with multiple logistic regression, controlling for age, Injury Severity Score, Abbreviated Injury Score (for a head injury), and admission blood pressure, the later period is associated with a 31% decrease in overall odds of death (P=.047) and a 42% decrease in odds of death among patients with severe head injury (an Abbreviated Injury Score, Ն3; P=.03). Conclusion:The implementation of a full-time trauma service is associated with improved timeliness of triage and therapeutic interventions and improved patient outcomes.

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“…Because training, experience, and performance of all personnel in attendance influence trauma outcomes, our comparable outcomes between study groups also suggest that consistency of care is given by the ED and hospital staff (8). Based on our initial hypotheses and clinical evidence supporting the presence of attending trauma surgeons for category I alerts, we originally anticipated deducing that attending trauma surgeons should be present initially for all category II trauma activations (7,10). For example, after assessing two university-based trauma centers, Rogers et al reported that the absence of attending surgeons resulted in errors in judgment more frequently than when the attending surgeons were present and that longer resuscitation and transport times occurred when patients were evaluated initially by surgical residents, which translates into a significantly higher mortality rate (10).…”

Section: Discussionmentioning

confidence: 94%