Trauma surgeon becomes consultant: evaluation of a protocol for management of intermediate-level trauma patients.
OBJECTIVE
At our level 1 pediatric trauma center, 9-54 intermediate-level ("level 2") trauma activations are received per month. Previously, the surgery team was required to respond to and assume responsibility for all patients who had "level 2" trauma activations. In 8/2011, we implemented a protocol where the emergency room (ER) physician primarily manages these patients with trauma consultation for surgical evaluation or admission. The purpose of this study was to prospectively evaluate the effects of the new protocol to ensure that patient safety and quality of care were maintained.


METHODS
We compared outcomes of patients treated PRE-implementation (10/2010-7/2011) and POST-implementation (9/2011-5/2012), including surgeon consultation rate, utilization of imaging and laboratory testing, ER length of stay, admission rate, and missed injuries or readmissions. Statistical analysis included chi-square and Student's t-test.


RESULTS
We identified 472 patients: 179 in the PRE and 293 in the POST period. The populations had similar baseline clinical characteristics. The surgical consultation rate in the POST period was only 42%, with no missed injuries or readmissions. The ER length of stay did not change. However, in the POST period there were significant decreases in the admission rate (73% to 44%) and the mean number of CT scans (1.4 to 1), radiographs (2.4 to 1.7), and laboratory tests (5.1 to 3.3) ordered in the emergency room (all p<0.001).


CONCLUSIONS
Intermediate-level pediatric trauma patients can be efficiently and safely managed by pediatric emergency room physicians, with surgical consultation only as needed. The protocol change improved resource utilization by decreasing testing and admissions and streamlining resident utilization in an era of reduced duty hours.
Baylor College of Medicine Departments of Pediatric Surgery.
Sara C
SC
Fallon
Baylor College of Medicine Departments of Emergency Medicine.
David
D
Delemos
Texas Children's Hospital Trauma Program.
Daniel
D
Christopher
Texas Children's Hospital Trauma Program.
Mary
M
Frost
Baylor College of Medicine Departments of Pediatric Surgery.
David E
DE
Wesson
Baylor College of Medicine Departments of Pediatric Surgery. Electronic address: bnaik@texaschildrens.org.
Bindi
B
Naik-Mathuria
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D003951:Diagnostic Errors; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000706:statistics & numerical data; D005260:Female; D013502:General Surgery; D006760:Hospitalization; D006776:Hospitals, Pediatric / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007396:Internship and Residency; D008297:Male; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team; D011446:Prospective Studies; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013781:Texas / Q000453:epidemiology; D014193:Trauma Centers / Q000458:organization & administration* / Q000706:statistics & numerical data; D015599:Trauma Severity Indices; D019564:Unnecessary Procedures; D014947:Wounds and Injuries / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery / Q000628:therapy*
Intermediate-level trauma; Pediatric trauma; Quality improvement; Resource utilization