The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue 10

The Orthopaedic Forum | October 01, 2006

Level-I Orthopaedic Trauma Care: A Model for Longevity

Michael T. Archdeacon, MD, MSE¹; Peter J. Stern, MD¹

¹ Department of Orthopaedic Surgery, University of Cincinnati, College of Medicine, P.O. Box 670212, 231 Albert Sabin Way, Cincinnati, OH 45267-0212

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The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. One author (M.T.A.) is a paid consultant for Stryker, but the company had no input or involvement in this article.

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 Oct 01;88(10):2305-2309. doi: 10.2106/JBJS.E.01180

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Affiliation with a level-I trauma center imposes a heavy burden on any orthopaedic practice. This burden is manifested in the required trauma call; the issues centered on providing appropriate, timely care for trauma patients; and, finally, in the financial disincentive to providing trauma care1,2. These issues are expanded in terms of the required commitments to achieve success, including institutional support, support from the academic department chairman, and dedication from all members of the orthopaedic practice2-5. Although certainly not unique, the system developed at our medical center has demonstrated efficient, high-level care for patients with musculoskeletal injury. It has improved our ability to generate revenue for the department, and it has prevented "burnout" or turnover of the musculoskeletal traumatologists. We describe this model as an example of a system that has worked well in a level-I academic trauma center.

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Affiliation with a level-I trauma center imposes a heavy burden on any orthopaedic practice. This burden is manifested in the required trauma call; the issues centered on providing appropriate, timely care for trauma patients; and, finally, in the financial disincentive to providing trauma care^1,2. These issues are expanded in terms of the required commitments to achieve success, including institutional support, support from the academic department chairman, and dedication from all members of the orthopaedic practice^2-5. Although certainly not unique, the system developed at our medical center has demonstrated efficient, high-level care for patients with musculoskeletal injury. It has improved our ability to generate revenue for the department, and it has prevented "burnout" or turnover of the musculoskeletal traumatologists. We describe this model as an example of a system that has worked well in a level-I academic trauma center.

Elaboration on the difficulties associated with level-I trauma care is required to fully appreciate the success of our program. Required trauma call places considerable demands on individual orthopaedic surgeons. Trauma and injury occur throughout the day with no respect for work, family, or sleep schedules. Often the injuries require immediate evaluation and prompt surgical intervention. In light of a busy practice, the disruption caused by the need to provide immediate trauma care can result in the cancellation of elective surgeries or office visits. It can further disrupt already compromised family time. Off-hours care may drain the physician for the next day, as well as potentially compromise the outcome for the patient^6,7. Finally, patients with nonemergent conditions who move to the "add-on" schedule the following day further extend the time commitment for trauma call and the frustration related to trauma care.

To expand on these issues, the effect of trauma care at a level-I center on an orthopaedic department must be appreciated. First, the department chairman must successfully recruit full-time specialists dedicated to trauma care. Next, an appointed trauma director is responsible for organizing a call schedule, assuring availability on nights, weekends, and holidays. The chairman must support the director by requiring all members of the department to participate in the call burden. This director position is not dissimilar to the orthopaedic trauma director previously described by Bray for the management of a level-II trauma center³. The director must work with other members of the department as well as representatives from all other departments involved in trauma care to establish protocols that ensure appropriate musculoskeletal trauma care. These protocols can be derived from the Advanced Trauma Life Support program of the American College of Surgeons^8,9 and the Eastern Association for the Surgery of Trauma¹⁰. Additionally, the orthopaedic trauma director must manage a performance improvement or peer-review process, which ensures the highest level of care for every trauma patient⁵. Finally, the orthopaedic group needs to recognize and support priority access to the operating room in order to provide appropriate trauma care.

The role of the orthopaedic trauma team as the advocate for the trauma patient cannot be overemphasized. The development of care protocols, the performance improvement process, and the assurance of available operating rooms for emergent trauma care underscore the commitment of the institution and the department to achieve the highest level of patient care. As an example, in our institution, for a period of eighteen months, dedicated orthopaedic trauma rooms were not available. During that period, our performance improvement process documented an average of four to five open fractures per month that were delayed in going to the operating room for more than twelve hours. However, with the reestablishment of dedicated orthopaedic trauma operating rooms, over a twenty-four-month period, the number of open fractures delayed for more than twelve hours decreased to zero. As demonstrated at our institution and others, a well-developed orthopaedic trauma service ensures the best care for patients with an orthopaedic injury under all circumstances^1,3,4,6,7,11.

Financially, the department and institution must support the trauma program². The epidemiology of trauma and injury demonstrates that many affected patients have inadequate financial resources for medical care^5,12,13. When examining the effect of providing emergent care to "unfunded" patients, at the expense of patients scheduled for a procedure or an office visit, it is readily apparent that caring for such patients can result in an additional expense for the physician practice. However, a financial gain may result for the hospital or institution on the basis of community or state-assisted support for indigent care^4,5. Thus, there are considerable practice, financial, and lifestyle disincentives for orthopaedic surgeons with elective, nontrauma practices when they consider orthopaedic trauma care. Additionally, surgeons who are not fellowship-trained in orthopaedic traumatology may be less comfortable managing severe injuries and performing reconstructions on a definitive basis¹⁴. However, the advantages of an orthopaedic trauma service, including lifestyle and practice preferences, have been established, and, in one institution (Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina), the majority of surgeons believed that the entire department was improved with the development of an orthopaedic trauma service⁴.

There are several prerequisites for overcoming the problems associated with the management of an orthopaedic trauma care program and providing efficient, timely, high-quality care. First and most critical is institutional support. Hospitals that provide trauma services have the potential to generate substantial revenue⁵. The hospital administration must recognize the importance of orthopaedic trauma care, as well as the importance of having that care directed by an orthopaedic traumatologist. The hospital must provide appropriate resources in terms of access to the operating room, financial support to orthopaedic surgeons for trauma call, and an adequate number of dedicated physician extenders^1-3,5,14. Finally, the hospital should assist in the recruitment and retention of orthopaedic traumatologists.

Next, for an effective orthopaedic trauma care program, there must be a supportive department chairman. This support includes enforcing a fair distribution of the call burden. It also includes a revenue-sharing plan that does not penalize trauma surgeons for providing care to a largely unfunded population. Finally, the department chairman must provide appropriate academic and monetary compensation for the administrative and educational commitments of the traumatologists⁴.

The final component centers on the department. In terms of morale, this component weighs in heavily. In order to provide sophisticated orthopaedic trauma care, the department must adopt a team approach and recognize that the provision of this care is the responsibility of the entire department, not just the trauma surgeons^4,6,11. Nothing is more demoralizing than hearing comments such as:

—"You are the trauma guy; trauma call is your job."—"You don't generate enough revenue. I am supporting you."—"The clinic and consults are the trauma team's responsibility."

—"You are the trauma guy; trauma call is your job."

—"You don't generate enough revenue. I am supporting you."

—"The clinic and consults are the trauma team's responsibility."

Such statements create tension among department members and discourage a team approach to patient care and successful business. If the members of the department adopt a team approach, everyone benefits^4-6,11. The patients will receive the highest level of care, the practice will be recognized as the tertiary provider in the region, the strengths of each partner will be maximized, revenue will increase, individual physician lifestyle will improve, and resentment and/or "burnout" of the trauma surgeons can be prevented⁴.

In order for the system to be successful, there are three critical components. These include personnel requirements (Table I), hospital-based resources (Table II), and practice commitments (Table III). The model, our regional level-I trauma center, exemplifies such a system. Most analogous to the "shift work" systems in emergency medicine and anesthesiology, this model requires a team commitment to providing care based on injury and patient needs rather than on financial circumstances and physician availability. This system has helped to develop the scope and complexity of the trauma surgeons' practice by concentrating the care for all fracture patients, but it has limited the need for those surgeons to take the majority of call. Also, the system diminishes the effect of call on nontrauma surgeon partners by minimizing nighttime work, so that scheduled procedures and office visits for the following day are almost never cancelled. It also eliminates the necessity of performing "add-on" cases at the end of a busy workday after being on call. Finally, the nontrauma surgeon partners do not have to worry about definitive care or follow-up for patients with problems outside the surgeon's area of expertise. Most importantly, the system ensures the highest level of care for all trauma patients because definitive care for nearly all complex injuries is provided by musculoskeletal traumatologists. It must be recognized that this model does not address issues related to subspecialties, including hand, microvascular, and spine surgery. Additionally, a backup call system may be beneficial so that a fellowship-trained musculoskeletal traumatologist is available to assist in emergent care for injuries that fall outside the skill set of the on-call orthopaedist.

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TABLE I Personnel Requirements

Details and Responsibilities According to Role	Full-Time Equivalents
Orthopaedic trauma director	1.0
• Fellowship-trained orthopaedic traumatologist appointed by department chairman
• Establish and maintain an orthopaedic trauma performance improvement program
• Develop and implement patient care protocols
• Coordinate the trauma call schedule
• Serve as a delegate for the orthopaedic service when patient-care issues arise with other services or other institutions
• Participate in multidisciplinary conferences and quality improvement (including general trauma service quality improvement program)
Orthopaedic trauma surgeons	3.0
• Having an adequate number of traumatologists is an absolute requirement:
—Approximately one traumatologist is required for every 700 to 800 annual trauma admissions (estimate is anecdotal and based on the experience of a single trauma center)
—A minimum of two surgeons and potentially five or six depending on case volume and complexity
Orthopaedic nurse clinicians	3.0
• Emphasize preoperative and postoperative teaching as well as patient care
• Liaison between other services, particularly the general trauma service, the discharge planners, and social workers
• Work in the follow-up clinics and provide continuity of care
• Employees of the hospital (not a departmental cost center), but primary responsibilities are managed by the orthopaedic trauma director
• Estimate: one per trauma surgeon
Physician extenders (physician assistants or nurse practitioners)	3.0
• Assist at all levels of patient care, including emergency evaluations and consultations, hospital rounds, discharge planning, operating room, and office follow-up
• One of the most valuable assets on the service, as they provide continuity in patient care
• Expedite evaluation and treatment
• Department employees (department cost center, 90% subsidized by the hospital) but responsibilities are managed by the orthopaedic trauma director
• Estimate: one per trauma surgeon
Orthopaedic residents	Varies
• Varies depending on the number and size of residency
• 2 senior residents and 2 junior residents in our program
• Senior resident responsibilities:
—Coordinating trauma patient care
—Managing in-house patient care
—Assisting in surgery
• Junior resident responsibilities:
—Initial evaluation and treatment (with attending and/or senior resident supervision) of trauma patients
—Assist in surgery
• Supplemented by physician extenders if residents are not available
Research assistant	1.5
• Manages Institutional Review Board, Health Insurance Portability and Accountability Act, and patient safety regulations
• Liaison between the various research oversight committees, the hospital, the university, and the department
• Arranges follow-up studies and surveys for study patients
• Assists database manager
• Only required if clinical research is performed
• Department employee (not subsidized)
Database manager	0.5
• Abstracts and manages the orthopaedic trauma database
• Critical personnel for ensuring quality of care through a performance improvement process
• Makes data available for protocol-based research projects
• Ensures the security and backup of the database
• Department employee (not subsidized)

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TABLE I Personnel Requirements

Details and Responsibilities According to Role	Full-Time Equivalents
Orthopaedic trauma director	1.0
• Fellowship-trained orthopaedic traumatologist appointed by department chairman
• Establish and maintain an orthopaedic trauma performance improvement program
• Develop and implement patient care protocols
• Coordinate the trauma call schedule
• Serve as a delegate for the orthopaedic service when patient-care issues arise with other services or other institutions
• Participate in multidisciplinary conferences and quality improvement (including general trauma service quality improvement program)
Orthopaedic trauma surgeons	3.0
• Having an adequate number of traumatologists is an absolute requirement:
—Approximately one traumatologist is required for every 700 to 800 annual trauma admissions (estimate is anecdotal and based on the experience of a single trauma center)
—A minimum of two surgeons and potentially five or six depending on case volume and complexity
Orthopaedic nurse clinicians	3.0
• Emphasize preoperative and postoperative teaching as well as patient care
• Liaison between other services, particularly the general trauma service, the discharge planners, and social workers
• Work in the follow-up clinics and provide continuity of care
• Employees of the hospital (not a departmental cost center), but primary responsibilities are managed by the orthopaedic trauma director
• Estimate: one per trauma surgeon
Physician extenders (physician assistants or nurse practitioners)	3.0
• Assist at all levels of patient care, including emergency evaluations and consultations, hospital rounds, discharge planning, operating room, and office follow-up
• One of the most valuable assets on the service, as they provide continuity in patient care
• Expedite evaluation and treatment
• Department employees (department cost center, 90% subsidized by the hospital) but responsibilities are managed by the orthopaedic trauma director
• Estimate: one per trauma surgeon
Orthopaedic residents	Varies
• Varies depending on the number and size of residency
• 2 senior residents and 2 junior residents in our program
• Senior resident responsibilities:
—Coordinating trauma patient care
—Managing in-house patient care
—Assisting in surgery
• Junior resident responsibilities:
—Initial evaluation and treatment (with attending and/or senior resident supervision) of trauma patients
—Assist in surgery
• Supplemented by physician extenders if residents are not available
Research assistant	1.5
• Manages Institutional Review Board, Health Insurance Portability and Accountability Act, and patient safety regulations
• Liaison between the various research oversight committees, the hospital, the university, and the department
• Arranges follow-up studies and surveys for study patients
• Assists database manager
• Only required if clinical research is performed
• Department employee (not subsidized)
Database manager	0.5
• Abstracts and manages the orthopaedic trauma database
• Critical personnel for ensuring quality of care through a performance improvement process
• Makes data available for protocol-based research projects
• Ensures the security and backup of the database
• Department employee (not subsidized)

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TABLE II Hospital-Based Resources

Operating-room access

Ready access to the operating room—Commitment from hospital, chairman, and partnersDedicated trauma room available Monday through Friday from 6 am to 5 pm—Managed by orthopaedic trauma service—Emergent care provided for acutely injured patients and surgical emergencies—Débridement and definitive reconstructions provided for "in-house" trauma patients—Treatment for patients with less emergent conditions (i.e., ankle and hip fractures)An additional full-block room Monday through Friday—Reserved for the orthopaedic trauma service to perform elective procedures—Treatment of referred patients and/or those having complex or elective procedures (osteomyelitis, periarticular reconstructions, pelvic ring injuries, and nonunions and/or malunions)Trauma surgeons available weekdays from 6 am to 5 pm—After 5 pm, damage-control orthopaedics performed and staffed by on-call orthopaedist (trauma surgeons and nontrauma surgeons)—"Shift work" system is critical for long-term survival of the orthopaedic trauma surgeons—All traumatologists "share" the trauma caseload for the prescribed hours as noted above—Definitive trauma care is provided by the "covering" traumatologist regardless of who saw the patient on admission and regardless of the patient's financial status

Call stipend

Supplements trauma surgeon's incomeRewards the nontrauma surgeons for participating in the call scheduleSpecifics depend on the trauma volume, number of surgeons taking call, and overall financial burden

Incentives and recruitment

Factors that may precipitate early exodus from trauma care include stressful cases, unruly patient population, unpredictable hours, liability, and financial disincentivesOptions for the medical center to assist in the recruitment process—Assist financially with a signing bonus—Supplement malpractice premiums—Provide debt relief—Provide a practice supplement for unfunded patient careBenefits in addition to the financial commitment—Protection of trauma operating rooms and access to operating room—Assistance in practice development—Guaranteed availability of equipment and imaging devices

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TABLE II Hospital-Based Resources

Operating-room access

Call stipend

Incentives and recruitment

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TABLE III Practice Commitments

"All or none" concept

Trauma surgeons must provide care to all patients with a fracture or injury— Includes all funded and unfunded patients— To maintain financial and mental equality, all fracture work must funnel down to the traumatologists

Call

All orthopaedic surgeons required to participateDesigned to minimize the "load" of call on nontrauma partnersWeeknight call from 5 pm to 6 am"Damage-control orthopaedics" only— Emergent débridement of open fractures— Timely intramedullary nail fixation of lower extremity fractures— Application of spanning external fixators for periarticular fractures— Application of pelvic external fixators— Trauma surgeons accept all patients "passed on"Weekend call from 5 pm on Friday to 6 am on Monday— May be managed by a single surgeon or divided up among several surgeons— General orthopaedic cases managed as indicated— "Damage-control orthopaedics" as previously described— Complex injuries are provisionally stabilized and "passed on" to the orthopaedic traumatologist for definitive care"Backup" traumatologists available when necessary

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TABLE III Practice Commitments

"All or none" concept

Call

In terms of financial impact, our department employs three fellowship-trained orthopaedic trauma surgeons. The department receives a subsidy from the hospital that is equivalent to 1.5 full-time equivalents for a musculoskeletal traumatologist's salary and benefits. This monetary support is a composite of funds for uncompensated care, call stipend, and programmatic support. Revenue generated by the trauma surgeons results in a 63% net collection rate (includes payments received for the treatment of trauma patients and for elective procedures). All surgeons taking trauma call receive a stipend based on the number of call days. The stipend represents 19% of annual income for the trauma surgeons who average six nights of call per month. In comparison, for the other (nontrauma specialist) orthopaedic surgeons, the percentage of net collections per dollar billed is 96%, and these surgeons average two nights of call per month with 4% of their annual income generated from the call stipend. Compensation for call is weighted so that weekend and holiday call are reimbursed at 150% of the weeknight call stipend. The department chairman has a bonus structure that favors the surgeons who provide a larger volume of unfunded care. The annual bonus averages 7% of annual compensation for the trauma surgeons and 4% for the nontrauma surgeons. Finally, the trauma surgeons account for 38% of total revenues for the department and make up 34% of the surgeon workforce in the department. Although this system is not entirely equal in terms of call and physician compensation, we have found it to be both useful and beneficial. It emphasizes lifestyle and an equitable distribution of resources and finances; thus, longevity for the trauma surgeon becomes a viable option. This financial model is one of many possibilities, and each department and institution will have to modify the formula to meet their specific needs.

In regard to orthopaedic resident responsibilities, our orthopaedic trauma service is assigned two senior residents and two junior residents. The primary responsibilities for the senior residents consist of coordinating trauma patient care, managing the inhouse patient care, and assisting in surgery. The junior residents are primarily responsible for the initial evaluation and treatment (with attending and/or senior resident supervision) of trauma patients and for assisting in surgery. The distribution and responsibilities of the residents depend on the individual circumstances of each program; however, resident patient-care responsibilities can be supplemented with physician extenders in circumstances when residents are not available or are in short supply.

Although all aspects of this model are not applicable to every trauma center, the goal of this review is to clarify the components that influence the provision of orthopaedic trauma care and to present concepts that may be modified in order to address the individual needs of other trauma centers. The problems faced at level-I trauma centers are not unique and, according to the American Academy of Orthopaedic Surgeons (AAOS), these issues have reached a crisis state^1,2. In response, the AAOS appointed the Project Team on Trauma Care/On-Call Issues in May 2005. This task force has initiated an action plan to provide guidance and support for issues similar to those addressed in this article.

In summary, we believe that our model for orthopaedic trauma care is a "win-win" for all involved. Patients receive the highest quality of care available in a timely and efficient manner, and all patients, except for those seen at night with an absolute emergent condition, are treated by a fellowship-trained orthopaedic traumatologist. In terms of practice development, all partners take care of problems they are most interested in and most qualified and knowledgeable in managing. Financially, the efficiency of specialists caring for specialty problems and the ability to protect elective practices from the burden of trauma care improve productivity for the entire practice^4,5. The institution benefits because it is recognized by both the public and the medical community as a reliable resource for providing high-quality trauma care in an efficient and seamless manner. Thus, all involved parties—the patients, the surgeons, the department, and the institution—benefit.

Acknowledgements

Acknowledgements | References

Note: The authors acknowledge T. Toan Le, MD, and John Wyrick, MD, as contributing members of the orthopaedic trauma service.

References

Acknowledgements | References

American Academy of Orthopaedic Surgeons. Position statement. Improving America's trauma care system. Document 1111; 2003. 2003

Beaty JH. Project team addresses on-call issues. AAOS Online Bulletin. April2006. 2006

Bray TJ. Design of the Northern Nevada Orthopaedic Trauma Panel: a model, level-II community-hospital system. J Bone Joint Surg Am. 2001;83: 283-9.83283 2001 [PubMed][CrossRef]

Harris MB, Gregory SJ. The academic orthopaedic trauma service: an analysis of its financial viability and its impact on resident education and faculty job satisfaction. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2003Oct9-11; Salt Lake City, UT. 2003

Patterson BM, Vallier HA, Lombardo T, Meehan C. Orthopaedic traumatology: the hospital side of the ledger. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2004Oct8-10; Hollywood, FL. 2004

Bhattacharyya T, Vrahas MS, Morrison SM, Kim E, Wiklund RA, Smith RM, Rubash HE. The value of the dedicated orthopaedic trauma operating room. J Trauma. 2006;60: 1336-40.601336 2006 [PubMed][CrossRef]

Ricci WM, Schwappach JR, Leighton RK, Coupe KJ, Tucker MC. Is "after hours" surgery associated with adverse outcomes? Read at the Annual Meeting of the Orthopaedic Trauma Association; 2005Oct20-22; Ottawa, Ontario, Canada. 2005

American College of Surgeons. Advanced trauma life support program for doctors. 7th ed. Chicago: American College of Surgeons; 2004. 2004

American College of Surgeons. Trauma programs. Resources for optimal care of the injured patient: 1999. Chicago: American College of Surgeons; 1999. 1999

Eastern Association for the Surgery of Trauma. Trauma practice guidelines. East Northport, NY: Eastern Association for the Surgery of Trauma; 1998. 1998

Obremskey WT, Medina M. Comparison of intramedullary nailing of distal third tibial shaft fractures: before and after traumatologists. Orthopedics. 2004;27: 1180-4.271180 2004 [PubMed]

MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson TM, McCarthy ML. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma. 2000;14: 455-66.14455 2000 [PubMed][CrossRef]

MacKenzie EJ, Morris JA Jr, Jurkovich GJ, Yasui Y, Cushing BM, Burgess AR, DeLateur BJ, McAndrew MP, Swiontkowski MF. Return to work following injury: the role of economic, social, and job-related factors. Am J Public Health. 1998;88: 1630-7.881630 1998 [PubMed][CrossRef]

Orthopaedic Trauma Association. Orthopaedic Trauma Service Organization. OTA Committee on Health Policy and Planning. Rosemont, IL: Orthopaedic Trauma Association; 2006. 2006

Topics

emergency treatment ; longevity ; wounds and injuries ; trauma assessment and care

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Michael T. Archdeacon, Peter J. Stern; Level-I Orthopaedic Trauma Care: A Model for Longevity. The Journal of Bone & Joint Surgery. 2006 Oct;88(10):2305-2309.

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