Utilization of Orthopaedic Trauma Surgical Time: An Evaluation of Three Different Models at a Level I Pediatric Trauma Center

Abstract

Objective

Over the past decade, our institution has instituted three different scheduling models in an attempt to care for pediatric trauma at our Level I Trauma Center. This has been in response to a number of factors, including a limited number of physicians covering the call schedule, increasing competition for operating room (OR) time after hours (pediatric surgery, urology, neurosurgery), an attempt to fully utilize OR time during the daytime, fully staffed hours, and optimizing patients' timeliness to surgery. We examined the three on‐call systems in place at our institution to determine whether a more flexible approach to pediatric trauma call resulted in delays in treatment.

Methods

We retrospectively reviewed patient records for three distinct 1‐year periods with three different surgical call schedules: (i) a traditional call schedule in which the call physician was responsible for patients who presented to our emergency room; (ii) a half‐day trauma block OR reserved the morning following call; and (iii) a full‐day trauma block. Variables included date of injury, time of admission, admission diagnosis, cause of injury, and OR procedure and start time.

Results

We reviewed 951 cases over the entire study, 268 during the traditional call schedule, 282 during the half‐call block and 401 over the time period of the full‐day block. Mechanisms of injury were similar among the three groups, with falls and motor vehicle accidents being the leading causes. The average delay time was 17:40 for the traditional call group, 15:10 for the half‐block call group, and 15:09 for the full‐day block group. Our findings suggest that there was a high incidence of cases performed on weekdays after peak staffing hours with a traditional call model (59%). In contrast, half‐day and full‐day block models saw only 4% and 1% of the cases performed after peak staffing hours, respectively. There was a statistically significant difference in the number of patients admitted to the OR among the three groups (χ² = 488.8449, P < 0.0001). The number of patients seen during Monday through Friday was also statistically significant among the three groups (χ² = 382.0576, P < 0.0001).

Conclusions

The institution of more flexible and physician‐directed half‐call and full‐day blocks did result in delays in treatment. However, it also has demonstrated benefits to patients in reducing the number of operative cases performed after weekday peak staffing hours; helped our institution better manage its staffing and financial resources; and provided the treating surgeon flexibility in determining the timing of operative care.

Introduction

Utilization of resources to manage the volume of trauma that may present to a pediatric level I trauma center is a challenge to physicians, hospital administrators, nursing staff, and operating room (OR) personnel1, 2. The overall goal for physicians is to respond to orthopaedic emergencies in a timely manner. This may include immediate trips to the OR despite the time of day, intervention the same evening following an office or operative day, or even the next day following the office or OR depending on the injury and the time of presentation. There are occasions when a partner who is available in the OR is able to perform a case to facilitate completion of the add‐on cases. This scenario may adversely affect patient care, may add to hospital length of stay, and may contribute to physician burn out. Previous studies have suggested that surgical interventions performed after routine hours are associated with greater complication rates, adversely affecting length of stay, overall cost of treatment, and mortality rates3, 4, 5, 6, 7, 8, 9, 10.

Additionally, the challenges posed by this model may have a significant impact on the quality of life experienced by medical providers. Other on‐call models offer alternatives to the traditional call schedule. As some residency programs have evolved to a night float position to cover calls, so may some institutions arrange for night coverage of call duty. Other programs may arrange for a surgeon of the week. Reserving a surgical suite for an on‐call surgeon the day following his/her call is another option to permit care for the volume of trauma that may present itself to a level I emergency room (ER)11. The added advantage to this model is in continuity of care. The decision for intervention is made by the same surgeon performing that procedure instead of signing out to a colleague.

Over the past decade, our institution has instituted three different models in an attempt to care for trauma at our Level I Trauma Center. This has been in response to a number of factors, including a limited number of physicians covering the call schedule, increasing competition for OR time after hours (pediatric surgery, urology, neurosurgery), an attempt to fully utilize OR time during the daytime fully staffed hours, and optimizing patients' timeliness to surgery.

Our intent with this study was to help document our impression that patients were receiving care in a timely manner and that we were optimally utilizing our OR resources.

Materials and Methods

We chose to look at three different time periods in which we implemented three distinct models for covering call. Our institution functioned for many years with a traditional call schedule in which the call physician was responsible for patients who presented to our ER and would care for them either as emergencies, the evening of admission, or the day or evening following admission. The second model allowed for a half‐day trauma block OR reserved the morning following call. This allows the call physician the opportunity to care for the patient on the day of admission or electively in the trauma block the following day. The last model allowed for a full‐day trauma block, again giving the on‐call physician a number of options for caring for the patient. The obvious requirement for the latter two models was that the on‐call physician has a half‐day or full‐day time slot available for coverage the day following call. The transition from the half‐day to full‐day OR block was made secondary to a steadily increasing patient volume.

After Institutional Review Board approval we performed a retrospective evaluation of orthopaedic surgical admissions at our institution from June 2002 through August 2009. Only patients admitted through the emergency department on an urgent basis were included. There were no further exclusions. Our state has instituted a trauma policy that all children younger than 16 years of age are taken to a level I pediatric trauma facility. The review included a total of 951 surgical cases over three distinct time periods. Time periods chosen were a 1‐year period of traditional call from October 2001 through September 2002, a 1‐year period of half‐call block from October 2003 through September 2004, and lastly, a full‐day block from October 2008 through September 2009. Variables evaluated included date of injury, time of admission, admission diagnosis, cause of injury, and OR procedure and start time.

Simple means were calculated utilizing Microsoft Excel 2010. χ² testing was performed to compare variables among the three groups. Statistical analysis was conducted using SAS 9.2 (SAS, Cary, NY, USA). Statistical significance was set at P < 0.05.

Results

We reviewed 951 cases over the three 1‐year time periods. In total, 268 were treated during the traditional call schedule, 282 during the half‐call block and 401 over the time period of the full‐day block. The characteristics of patients across the three blocks are shown in Tables 1, 2, 3. As our institution would only provide for staffing of the block rooms during the traditional work week Monday through Friday, we separated the data for those cases performed on Monday to Friday and those performed on Saturday and Sunday. The mechanism of injury between the three groups was very similar, with falls and motor vehicle accidents being the leading causes. Of the 260 patients admitted during the traditional call period, 177 (68%) were taken to the OR during the conventional Monday–Friday work week. In total, 14 of the 260 (5%) were open injuries. Of these cases, 41% had a procedure start time during hours of maximal nursing staffing (7 a.m.–5 p.m.). There was an average delay time of 17:40 from presentation for this group.

Table 1.

Traditional on‐call (268 patients)

Time frame	Patients (n, %)	Average start time overall	Mon–Fri OR (n, %)	Average start time (Mon–Fri)	Sat–Sun OR (n, %)	Average start time (Sat–Sun OR)
07:00–12:00	52 (20)	10:01	24	10:09	28	9:55
12:01–17:00	57 (22)	14:42	49	14:43	8	14:38
17:01–06:59	151 (58)	15:15	104	20:36	47	15:23
Totals	260*		177 (68)		83 (32)

*Eight patients had unknown operating room (OR) start times. Mon, Monday; Fri, Friday; Sat, Saturday; Sun, Sunday.

Table 2.

Half operating room (OR) block (282 patients)

Time frame	Patients (n, %)	Average start time overall	Mon–Fri OR (n, %)	Average start time (Mon–Fri)	Sat–Sun OR (n, %)	Average start time (Sat–Sun OR)
07:00–12:00	261 (93)	9:45	200	9:41	61	9:56
12:01–17:00	9 (3)	12:46	6	12:27	3	13:25
17:01–06:59	12 (4)	14:12	8	11:45	4	19:06
Totals	282		214 (76)		68 (24)

Mon, Monday; Fri, Friday; Sat, Saturday; Sun, Sunday.

Table 3.

Full operating room OR block (401 patients)

Time frame	Patients (n)	Average start time overall	Mon–Fri OR (n)	Average start time (Mon–Fri)	Sat–Sun OR (n)	Average start time (Sat–Sun OR)
07:00–12:00	327 (82%)	9:40	222	9:41	105	9:38
12:01–17:00	69 (17%)	13:34	48	13:35	21	13:31
17:01–06:59	5 (1%)	14:01	4	16:39	1	3:30
Totals	401		274 (68%)		127 (32%)

OR, operating room; Mon, Monday; Fri, Friday; Sat, Saturday; Sun, Sunday.

For the half‐day call block group, 214 of the 282 (76%) cases were performed during the Monday–Friday period. Ten of the 282 (3.5%) in this groupwere open fractures. Overall 206 of the 214 (96%) patients had their procedures start between 7 a.m. and 5 p.m., with an average delay of 15:10.

For the full‐day block group, 274 of 401 (68%) cases were performed during the routine work week Monday through Friday. In this last group, 270/274 (99%) had their procedures start during hours of maximal staffing, with average delay time of 15:09.

There was a statistically significant difference in the number of patients admitted to the OR among the three groups (χ² = 488.8449, P < 0.0001). The number of patients seen during Monday through Friday was also statistically significant among the three groups (χ² = 382.0576, P < 0.0001). A comparison of the number of Monday–Friday patients to the OR between the traditional block and the full OR block showed a statistically significant difference (χ² = 321.8919, P < 0.0001), as did a comparison between the number of Monday–Friday patients in the traditional block and the half and full OR blocks combined (χ² = 362.1327, P < 0.0001).

Discussion

The success of trauma care systems depends heavily on the collaborative efforts of many health‐care professionals. As specialists integral to the delivery of trauma care, orthopaedic surgeons have a commitment and responsibility to aid in defining best‐practice guidelines. As part of this effort, researchers have focused on the relationship between after hours versus regular daytime hours in the OR and outcomes. Chacko et al. reviewed 767 consecutive patients with femoral neck fractures, dividing their time of surgery into the same three categories as our study. They found that the duration of surgery was significantly longer in the after‐hours patients, correlating with increased blood loss. While the authors found that some hip fracture patients would benefit from an earlier operation, even if after hours, they reported a decreasing trend in mortality with operations in a dedicated daytime trauma room staffed by a traumatologist3. Other studies have demonstrated increased medication error rates9, higher complications among specific patient populations8, and increased mortality6, 7 among patients treated after hours or on weekends.

In addition, a reliance on after‐hours treatment may have important economic implications. Schenker et al. studied costs related to the performance of after‐hours operative debridement of open fractures, using the National Inpatient Sample for 2009 (17,414 open tibia fractures). They estimated that the total additional cost for after‐hours operative debridement of these fractures at a level I trauma center was between $2.2 million and $4 million annually, meaning that elective delay of operative treatment, when appropriate, could result in considerable savings to the health‐care system10.

Our study is an attempt to describe three different call models and determine whether there were any differences in timeliness to the OR. Our findings suggest that there was a high incidence of cases performed on weekdays after peak staffing hours with a traditional call model (59%). In contrast, half‐day and full‐day block models saw only 4 and 1% of the cases performed after peak staffing hours, respectively. This shift may be largely attributed to delayed procedure starts for those patients admitted during off hours that can be appropriately stabilized and triaged for the OR the next morning. Delayed treatment for many common orthopaedic injuries has been shown to be safe and effective. The most common fracture operatively treated at this institution is the supracondylar humerus fracture. To date several studies have been published on the outcomes of these fractures after surgical delay12, 13, 14, 15, 16. All of the studies reviewed found no increase in the complication rate, which has further allowed surgeons to address these injuries in a more delayed fashion. We emphasize that an open line of communication between orthopaedic residents, emergency room personnel, hospital, and OR staff, and on‐call physicians is vitally important to the successful implementation of any model incorporating delayed treatment. There is an inherent balance that must be made in managing each patient. The severity of the injury, the patient's stability, the risk of waiting, the equipment needed, and the staffing available all must be taken into account by the treating surgeon when deciding when it is appropriate to proceed to surgery.

The lifestyle of a pediatric orthopaedic surgeon serving a level I trauma center demands considerable personal sacrifice. Concerns for manifestations of depression, substance abuse, job satisfaction, and burnout are notable, with burnout the most common among these17, 18, 19. Several factors contributing to physician burnout have been reported, including length of training, long work hours, and career–family imbalance. These many factors may be adversely affected by a traditional call model. A recent study by Balch et al. suggested there was a significant correlation between increasing night call duties, increasing overall work hours, and detrimental impacts on surgeons in both their professional and personal life20. Unfortunately, the negative consequences of these workload stresses can be significant for patients and surgeons alike. The development of an on‐call model that optimizes patient care with considerations of the well‐being of surgeons is readily apparent.

There are inherent weaknesses in our retrospective study design. Data from this study are derived from a single institution. There were a number of different surgeons making decisions for surgery on a wide spectrum of patients and injuries. Finally, sample sizes are varied, presumably secondary to the regional and episodic nature of trauma volume in our community.

In summary, the evaluation of these data has supported the continuation of a more flexible call model at our level I pediatric trauma facility. Administrators, nursing staff, and surgeons alike continue to be supportive of this model. It has demonstrated benefits to patients in reducing the number of operative cases performed after weekday peak staffing hours; helped our institution better manage its staffing and financial resources; and provided the treating surgeon flexibility in determining the timing of operative care.