Treating trauma—not as scary as you think

A unique service makes hospitalists the primary physicians for certain trauma inpatients.

It was a literature search that made Denetta Sue Slone, MD, and Patricia Howell, MD, realize the uniqueness of their program at Swedish Medical Center in Denver, Colo. Dr. Slone, a trauma surgeon, and Dr. Howell, a hospitalist, work together on the hospital's nonsurgical trauma medical (TMED) service.

The physicians recently collaborated on a research paper about the TMED service, which puts trauma patients in the care of hospitalists. But before their study was published in the April 2009 Surgery, their combined literature search for “trauma” and “hospitalist” yielded no results.

Drs. Slone and Howell hope to change that fact by encouraging other physicians and hospitals to follow their lead in making hospitalists the primary physicians for certain trauma inpatients. The Colorado TMED team has developed an algorithm to determine which trauma patients could benefit from more medical than surgical management (see box, next page).

Their recent study tested out the algorithm by comparing pre-TMED patients with those treated by the service, and found that rates of mortality, complications and placement to rehab were the same, although length of stay increased slightly under the service.

Drs. Slone and Howell expanded on their case for TMED in a recent interview.

Q: How did the TMED service get started?

A: Dr. Slone: It was my predecessor, Mike Kraun, who was the director of the trauma service. A lot of these [trauma] patients had more medical issues than they had trauma issues. You know, the elderly patient who tripped on [his] oxygen cord and broke [his] arm. They come into the hospital with not major trauma issues that require surgeons, but medical issues that require people like Dr. Howell and her group. [Dr. Kraun] went around and talked to all the medical groups and said, “Would you like to be part of the medical service?” Dr. Howell's group stepped up.

Dr. Howell: He had talked with services around the country and many of them were using physician assistant models to assist with some of the medical patients. [Dr. Kraun] was looking for a more physician-oriented level of care.

Q: How did you decide which patients would be treated by hospitalists?

A: Dr. Howell: A lot of it's based on the American College of Surgeons (ACS) and recommendations they have.

Dr. Slone: We were very nervous about how we were going to sell this to the American College [of Surgery] because we clearly exceed their limits in terms of admission rates. They have indicated that all trauma is to be taken care of by surgeons and therefore they check you every year to make sure that you haven't allowed any of the trauma patients to be admitted to a medical doctor. If I remember correctly, we were hitting 15% or 20% of the trauma service. They have very specifically said you need to keep your medical admissions under 10%.

We were both prepared for a disaster…[but] we were pleasantly surprised when they accepted the concept. What we did was find a very clear definition of the patients who would go to the trauma medicine service and made it in algorithm form, so the emergency physicians could use it. It's basically a single-system injury. So, for example, if someone has a ground-level fall and breaks three ribs or less, that could go to medicine. If they break more than that, then they have to go to trauma.

Dr. Howell: At the same time, there's crossover. The more severely injured often have many medical issues as well. In those, we'll serve in more of a consultant role, to assist with the medical management.

Q: How have surgeons responded to the program?

A: Dr. Slone: We love it. We had no role with the 97-year-old that fell and broke her left leg. We don't do the surgery—the orthopedic surgeon does. We certainly couldn't manage all the medical issues. The biggest thing we found was how helpful the medical service was at getting the person through the system into the right place after their hospitalization.

Q: How has the experience been for hospitalists?

A: Dr. Howell: When I interview hospitalists and tell them that we're at a Level I trauma center and we do some primary admits in trauma and consultation on other trauma patients, at first their eyes get huge. Because I think in general, hospitalists really have had no role in trauma before. But once they get involved they realize what they'll be responsible for as opposed to what the trauma surgeons are doing. As hospitalists, we're not running into ER bays for bleeding patients with severed limbs. We're involved in a lot of the same medical issues that we're involved with in our standard population.

Q: What challenges have you faced in making this work?

A: Dr. Howell: There's a lot of shared learning that goes on as far as acceptable goals for transfusion in trauma patients and the pain management style.

Dr. Slone: It's learning each other's styles and being able to mesh those styles. It took a while, maybe a year or six months. About six months ago we even had a dinner where we all got together and went over what's working and what's not working. We probably need to do that every six or seven months just to make sure the ship is moving in the right direction. It's hard. Training of hospitalists and training of surgeons is like light-years apart in terms of what their emphasis is.

When Dr. Kraun first set this up, one of the things that he had to prove to the ACS was that the hospitalists were clearly involved as key members. They weren't just consultants. They're required to do certain continuing medical education training. They have a certain number of hours a year that they have to do trauma courses. They are involved in all of our committee meetings, all of our decisions, all of our review of cases.

Dr. Howell: As far as time, that first year, you really have to do a lot of communicating until you get some of your protocols understood and melded together.

Q: Your study suggests that a TMED service could make trauma centers more efficient. Could you explain that?

A: Dr. Howell: Across the country, there's a shortage of trauma surgeons, so what you want your trauma surgeons doing is responding to events in the emergency room and really taking care of critically injured patients. You don't want them sitting down trying to figure out which of the five [congestive heart failure] medicines you want to continue. There's some utility in freeing up your trauma surgeons to focus more on the important aspects of trauma that will help system-wide across the country.

From the single-patient perspective, where hospitalists have really proved their worth is in system integration and systems management. From the door to the exit, we're integrated from the trauma surgeon into the disposition and follow-up care of these patients. And obviously when we get involved sooner rather than later, we're able to help manage their medical problems through the course of their stay so it's not having such an impact on their care.

Q: Should every hospital adopt this model?

A: Dr. Slone: I think everybody should be doing it. But maybe our model works because of our circumstances. I don't know. Everybody's got to be dealing with the same problems that we were. The elderly patient population is growing geometrically and so I just can't imagine that it wouldn't work in every place.

Dr. Howell: I totally agree. There are of course trauma patients that are 25 years old and in a car accident and there are very few medical issues to manage, but we don't get involved in those. We're only involved where we're needed. Anywhere you have a hospital that is big enough to have a hospitalist and do trauma, I think there's a role for this.

Q: Any advice on setting up a TMED service?

A: Dr. Slone: I think the survivability of a system like this really depends on the trauma medicine service setting up two lines of care because there's too much variability in the volume of trauma patients. If all these guys did was exclusively trauma, there could be some starving weeks.

Dr. Howell: Don't be afraid to get in there and get your feet wet. Because trauma training for hospitalists has been fairly minimal, I think it scares people. But if you work with your trauma surgeons, all of those obstacles are fairly easily overcome. The benefits to your patients, the hospital and your trauma surgeons are very well worth the effort that you put into it. For a hospitalist program, it helps to integrate you into an important part of the hospital.

I think it's an interesting new line. I think people should really get involved in it. It's fascinating care. It adds a whole other facet to our jobs that helps keep it interesting.