title: An initiative by midlevel providers to conduct tertiary surveys at a level I trauma center.
abstract: BACKGROUND
  Increased patient volume and residents' work hour restrictions have escalated the workload at trauma centers. Because tertiary surveys (TSs) are integral to care, midlevel providers (MLPs) can help streamline this time-consuming process. In this study, we implemented a care plan in which MLPs conduct all TSs, initiate appropriate consultations, and offload residents' work hours.
  
  
  METHODS
  From January 2007 to December 2008, we conducted a prospective evaluation of an initiative in which MLPs performed all TSs within 48 hours of admission. A TS consisted of a complete history and physical examination, follow-up of radiologic interpretations, and appropriate consultations. Data included patient demographics, incidence of additional diagnoses noted during TSs and reduction in residents' work hours. Data are presented as mean +/- standard error.
  
  
  RESULTS
  During the 2-year period, there were 5,143 patients admitted to the trauma service. The mean age was 36 years +/- 4.8 years, and mean Injury Severity Score (ISS) was 14.2 +/- 4.2. Overall mortality was 5%. Blunt mechanisms accounted for 85%, and penetrating mechanisms resulted in 14% of injuries. MLPs conducted TSs in 56% of patients during the first year and 76% in the second year. In 80 patients (mean age of 44 years +/- 7.1 years, mean Injury Severity Score 21.7 +/- 2.8; p < 0.05 vs. entire cohort), TSs revealed additional injuries, for an incidence of 1.5%. The majority of these diagnoses were of "minor" fractures, half requiring consultations, and 9% necessitating operative intervention. Residents' workload was reduced by 1,802 hours.
  
  
  CONCLUSIONS
  Implementation of a MLP initiative to conduct TSs in trauma patients can achieve a consistent and comprehensive workup while offsetting residents' workload and helping to ensure compliance with the 80-hour resident work policy.
authors.affiliation: FH Sammy Ross Jr Trauma Center, Carolinas Medical Center, Charlotte, North Carolina 28232-2861, USA. toan.huynh@carolinashealthcare.org
authors.forename: Toan T
authors.initials: TT
authors.lastname: Huynh
authors.forename: Angela H
authors.initials: AH
authors.lastname: Blackburn
authors.forename: Darlene
authors.initials: D
authors.lastname: McMiddleton-Nyatui
authors.forename: Kelly R
authors.initials: KR
authors.lastname: Moran
authors.forename: Michael H
authors.initials: MH
authors.lastname: Thomason
authors.forename: David G
authors.initials: DG
authors.lastname: Jacobs
mesh_terms: D000328:Adult; D002985:Clinical Protocols; D003951:Diagnostic Errors / Q000451:nursing / Q000517:prevention & control / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008487:Medical History Taking / Q000379:methods / Q000706:statistics & numerical data; D008505:Medical Staff, Hospital / Q000458:organization & administration; D008875:Middle Aged; D009657:North Carolina / Q000453:epidemiology; D009722:Nurse Practitioners / Q000458:organization & administration*; D015403:Nursing Evaluation Research; D010343:Patient Admission / Q000706:statistics & numerical data*; D010808:Physical Examination / Q000451:nursing / Q000706:statistics & numerical data; D015397:Program Evaluation; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D014193:Trauma Centers / Q000458:organization & administration; D014194:Traumatology / Q000458:organization & administration; D016526:Workload / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000175:diagnosis* / Q000453:epidemiology