The level-II trauma center has been defined by
the American College of Surgeons as "a hospital capable of delivering
definitive trauma care regardless of the severity of injury."1 In geographically isolated areas,
the level-II center frequently assumes the responsibilities of the
level-I center, including education, systems development, leadership,
and research.
Although much has been written about the general surgical aspects
of trauma, very few articles in the literature offer the orthopaedic
surgeon guidelines for the design, development, implementation,
and maintenance of orthopaedic trauma panels in community or level-II
trauma systems. In the current article, these specific issues are
discussed and questions regarding the daily functions of orthopaedic
trauma care in a community system are addressed.
The Reno, Nevada, trauma system is a unique level-II community
trauma program that has successfully fulfilled the designation criteria
of the American College of Surgeons2.
The Northern Nevada Orthopaedic Trauma Panel functions as an integral
part of the trauma program and can serve as a model system for other
programs in the early developmental phase or for programs having problems
maintaining high practice standards. This program has withstood
the critical recertification process set forth by the American College
of Surgeons' Committee on Trauma.
The Northern Nevada Orthopaedic Trauma Panel was designed in
1994 as a consult service to the Washoe Health System Trauma Program
for the management of orthopaedic trauma. The panel is composed
of orthopaedic surgeons who are members of several different private
group practices in Reno, Nevada. The panel is open to orthopaedic
surgeons who are committed to the enhancement of trauma care and
are willing to participate in trauma education and hospital trauma-committee
activities. The current panel consists of fifteen board-certified
orthopaedic
surgeons under the direction of a subspecialty-trained orthopaedic
traumatologist (Table I). The panel members have signed a practice
agreement, and, in return, they receive a monthly stipend from the
hospital administration for their time and services.
Traumatic injuries are a leading cause of death and disability
in all age groups; however, these injuries have a major impact on
younger patients because they result in an inability to work and
generate income. In the years leading up to 1992, traumatic injury
ranked as the fifth leading cause of death in the United States3. As an example of the magnitude of
this problem, 62.1 million traumatic injuries resulting in 412.1
million restricted-activity days were reported in the United States
in 19934. However, trauma care
remains critically underfunded compared with the treatment of diseases with
higher advocacy profiles, such as cancer, cardiovascular disease,
and blood-borne illnesses.
Rural practices are confronted with difficult challenges related to
trauma care and systems development. Rural community trauma-care
systems are usually faced with special logistical circumstances,
including the need to transport injured patients over long
distances, the economic hardships of practicing medicine in a small
town, the lack of sophisticated emergency-care delivery systems,
and the critical nature of managing common, blunt-trauma injuries.
The probability of death caused by a traumatic injury is higher
in rural areas, and two-thirds of all motor-vehicle-related deaths
occur in these areas5. Therefore,
rural communities are generally underserved, yet they are faced
with difficult trauma-management problems.
One of the major obstacles encountered by rural physicians is
the potential lack of focused suspicion for the hidden injury6. The low volume of traumatic injuries
in rural areas can result
in missed injuries. Without the high-technology imaging capabilities
and diagnostic tools that are readily available to urban practitioners,
it stands to reason that there are missed injuries and, therefore,
higher morbidity in the rural setting. Rural motor-vehicle accidents
generally occur at high velocities, and emergency medical-response
times are usually prolonged compared with those in urban areas6. According to U.S. News and
World Report, only 50% of emergency medical service calls
were answered within ten minutes in rural settings7. This combination of high-velocity
trauma and slow response times results in increased morbidity and
mortality.
Northern Nevada has most, if not all, of the challenging characteristics
commonly mentioned in the literature on rural trauma care. Not only
is there the difficulty of long transport times from small towns;
the weather ranges from hot desert summers to freezing mountain
winters, creating patient-exposure problems. The multiple recreational opportunities,
including skiing, snowboarding, all-terrain-vehicle use, motocross,
hang gliding, and rock-climbing, all have intrinsic risks and special
injury patterns associated with the biomechanics of the wounds.
Other social issues, which are difficult to quantitate, are exemplified
by patients from nearby larger communities who demand to be transferred
to their home physicians at odd hours and on holidays. Frequently,
these patients are medically unstable and cannot be readily stabilized
for transfer, or they have spine injuries that might create added
risk for air or ground transport.
One of the major goals of any community trauma hospital is to ensure
that patients do not die of simple or treatable injuries if they
have a reasonable probability of survival. In order to create a
workable system of injury classification in the prehospital setting,
the Reno Trauma System groups trauma patients into two major categories: trauma
blue and trauma green(Table II). This designation has orthopaedic implications,
as the multiply-injured patient is usually categorized as trauma
blue. These patients are known to benefit from early stabilization
as described by Bone et al.8.
The trauma-blue patient is more seriously injured and presents with
some physiological response to injury. Patients are categorized
into this group on the basis of any of the following findings: (1)
a Glasgow coma score9 of £13 points;
(2) a blood pressure of <90 mm/Hg; (3) a respiratory rate of <10
or >29 breaths/min; (4) an injury severity score10 of
>15 points; (5) a penetrating injury of the head, neck, torso, or groin;
(6) two proximal long-bone fractures; (7) flail chest; or (8) acute
paralysis.
The in-house trauma surgeon initially evaluates these patients, and
an orthopaedic consultation is sought immediately in the event of
long-bone or pelvic involvement.
The trauma-green patient is classified according to the mechanism
of injury and does not necessarily have a physiological response
to injury. Because of the rural setting of the Reno Trauma System,
the high probability of associated injury, and the potential for
physiological deterioration, these patients frequently receive a
formal trauma designation and often require evaluation by a trauma
surgeon. Some patients with single-bone injuries are admitted by
the orthopaedic surgeon primarily and may not require a trauma surgery
consultation. Patients are categorized into this group on the basis
of any of the following findings: (1) a motor-vehicle accident with
an 18-in (45.7-cm) intrusion into the passenger space, a 24-in (61.0-cm)
intrusion into the driver's side, rollover, or death of another occupant
in the same vehicle; (2) a high-impact blow to the body or face,
including a fall of 20 ft (6.1 m); (3) burns involving 15% of the
body or face or burns involving the
airway; (4) ejection during a motor-vehicle accident; (5) being struck
as a pedestrian by a vehicle traveling 20 mi/hr (32.2 km/hr); (6)
transport by an ambulance after a motorcycle, bicycle, all-terrain-vehicle,
or skiing accident; or (7) a penetrating wound to the proximal aspect
of an extremity.
There is another category of orthopaedic trauma that falls outside
of the classification system described above and that requires immediate
orthopaedic consultation. This category comprises patients with
unstable pelvic fractures, open fractures, compartment syndromes,
spine injuries, irreducible dislocations, and vascular injuries
associated with fractures. These patients can be managed by the
orthopaedic surgeon without the assistance of the trauma surgeon,
depending on the experience and training of the orthopaedic surgeon
on call.
In the rural setting, most centers, including Washoe Medical
Center, do not have designated pediatric trauma programs. In the event
of an isolated orthopaedic pediatric injury, the pediatric intensive-care
specialist or the pediatrician on call will usually assist in the
general care of the patient. In the event of a polytraumatic pediatric
injury, the entire trauma team is activated.
The Committee on Trauma of the American College of Surgeons has
published a resource manual entitled Resources for Optimal
Care of the Injured Patient: 199911.
The section "Clinical Functions: Orthopaedic Surgery" offers guidelines
regarding membership, facilities, and qualifications; however, there
are no specific recommendations on how to implement or maintain
a successful program. The recertification process is a critical
step advocated by the American College of Surgeons for reviewing the
program and following up on system deficiencies from the previous
year. The following discussion deals with the exact nature of a
model program designed within the general guidelines set forth by
the resource manual; this program has withstood the critical reevaluation
process for ongoing accreditation.
The general orthopaedic surgeon's primary responsibility as a
member of the community trauma panel is to examine the trauma patient
in the emergency department, to identify musculoskeletal injuries,
and to devise a plan of treatment. This frequently requires long-term
follow-up through the reconstruction, rehabilitation, and return-to-work
phases. General trauma surgeons are not primarily responsible for
admitting all patients to their service. Patients are frequently
transferred from the general trauma service to the orthopaedic service
for long-term management. The second major responsibility of the
orthopaedic surgeon is to share the intended treatment plan with
other team members and to notify the family of the orthopaedic status
of the patient. The final responsibility of the orthopaedic surgeon
is to participate in the clinical improvement program within the
orthopaedic trauma department and to support the trauma committee
on a rotational basis.
The mission of the Northern Nevada Orthopaedic Trauma Panel is
to
enhance the quality of trauma care in northern Nevada, to promote
continuing orthopaedic trauma education, and to strengthen interhospital
relationships with direct and indirect trauma-related services.
The panel is open to
all qualified orthopaedic surgeons in Reno, Nevada, who express
an interest in participation.
Qualifications
The qualifications to obtain and maintain membership on the panel
include the following.
Annual trauma education: Each member of the
Northern Nevada Orthopaedic Trauma Panel participates in an annual trauma-related
continuing-education program outside the local community. The member
must submit a report and be willing to discuss the experience with
the panel at its monthly meeting. The educational program can be related
to a subspecialty field of interest, such as pediatric fractures,
periprosthetic fractures, fractures in the upper extremities or
spine, and sports-related injuries. A quality-assurance file is kept
by the trauma office for documentation and review by the director
or by representatives of the American College of Surgeons during
subsequent site visits.
Board certification, recertification, and eligibility
for oral examinations by the American Board of Orthopaedic
Surgery: The American Board of Orthopaedic Surgery has
defined the
qualifications for certification as an
orthopaedic surgeon. The Northern Nevada Orthopaedic Trauma Panel
recognizes and accepts these requirements for participation on the
panel. These requirements include board certification and recertification
for practitioners with time-limited certificates. New practitioners
in the Reno area must be eligible for oral examinations in order
to participate on the panel. To gain final approval for membership,
each new practitioner must be proctored by an active panel member for
six months and be selected by a two-thirds vote of approval of the
active panel at the completion of the mentoring period.
Active hospital-staff status: Each member of
the Northern Nevada Orthopaedic Trauma Panel must obtain and maintain active
or senior hospital-staff status in accordance with Washoe Medical
Center activities, including the general orthopaedic services.
Call schedule: Each member of the Northern Nevada
Orthopaedic Trauma Panel is responsible for covering two-thirds
of his or her apportioned call days. This prevents the panel member
from having a colleague or practice partner cover those assigned
days in a disingenuous attempt to maintain panel membership. The
occasional missed call day will be excused for educational leave, vacation,
or true family emergencies as determined by the director. A mandatory
call-day quota is also used in an attempt to ensure that each panel
member participates in a sufficient number of resuscitations and polytrauma
fracture-management cases to maintain his or her trauma-care skills.
Orthopaedic Trauma Panel meetings: Each member
of the Northern Nevada Orthopaedic Trauma Panel must attend two-thirds
of the scheduled monthly panel meetings in order to maintain active
panel privileges. This keeps the panel member active and informed
and lessens the chance of scheduling conflicts with regard to on-call
and meeting responsibilities.
Quality assurance: Each member of the Northern Nevada
Orthopaedic Trauma Panel must participate in the quality-improvement
program. This
includes attending general trauma-committee activities and participating
on the orthopaedic quality-assurance panel (both on a rotational
basis) and presenting cases at morbidity and mortality conferences.
The administrative assistant to the orthopaedic trauma service randomly
selects cases for discussion each month. Each selected member reviews and
discusses these cases for panel-member education and quality-of-care
standards. The director decides whether appropriate standards were
breached and what action will be necessary to avoid the problem
in the future.
Response time: When called by the emergency department,
the panel member must respond within twenty minutes to
all designated trauma patients and must interface appropriately with
the general trauma surgeons and emergency physicians for management
strategies. Response time occasionally is monitored as a quality-assurance
filter for accreditation purposes.
Probation
Each panel member's performance is reviewed annually on the basis
of the requirements of the practice agreement, and the review is
presented in the form of a yearly report card. If the panel member
does not fulfill the qualifications listed above, he or she is placed
on six months' probation. All reasonable attempts are made to keep
the participant active and to allow excused absences at the discretion
of the trauma director. If the panel member has not completed the practice-agreement
requirements at the completion of the probation period, he or she
is disqualified from participation on the panel. Response time and board
certification are not subject to a probationary period as defined
above.
Voluntary Termination and Emeritus Status
Each participant on the Northern
Nevada Orthopaedic Trauma Panel must notify the director of orthopaedic
trauma, at least six months in advance, of a voluntary termination
of service. This allows for appropriate changes in scheduling and
avoids inconvenience to the other members of the panel. Participants
who have honorably served the panel will have an opportunity to
serve as emeritus practitioners. An emeritus practitioner retains
compensation
benefits from the call-reimbursement program and is not subject to
the requirements mentioned above. The emeritus status encourages
senior physicians to maintain their affiliation and on-call status
with the practice of trauma, supports the younger members, and provides
needed political insight into decision-making problems.
Responsibilities of the Director
The orthopaedic trauma director should be subspecialty-trained
in orthopaedic trauma and must fulfill all of the same practice responsibilities
as the panel participants. This keeps the director actively involved
in the daily practice of trauma care and ensures that he or she
understands the problems experienced by the panel members. The director
is responsible for scheduling all emergency orthopaedic coverage,
creating ad hoc committees for problem-solving,
negotiating trauma-service contracts, creating the monthly meeting
agenda, planning educational opportunities, grading members' performance
reviews, preparing the trauma service for certification reviews,
solving member and patient problems, and serving as member advocate in
the care of orthopaedic trauma patients.
General Orthopaedic Call
Not every orthopaedist in the Reno
area has elected to participate on the trauma panel. However, the hospital
bylaws require that physicians engage in emergency-call coverage
until the age of
fifty-five years in order to maintain staff privileges. Therefore, there
are two separate call schedules: one for the trauma panel and another
for the general orthopaedic emergency room. Conflicts regarding
who should care for patients are kept to a minimum by entering the
trauma patient into the trauma registry as required by the American
College of Surgeons. If the patient is entered into the registry,
the trauma-panel member, not the general-call orthopaedic surgeon,
is responsible for the patient's care and receives the compensation.
If the patient is not entered into the registry, the general orthopaedist
on call is responsible.
Contract Medicine
In today's contract-medicine environment, there is the potential
for a trauma physician or a member of the Northern Nevada Orthopaedic
Trauma Panel to be faced with a situation where the orthopaedic
surgeon on call is not part of the patient's health plan. It is
the standard practice of all orthopaedic surgeons on the trauma
panel to provide care independent of insurance conditions. In an
area of highly penetrated, managed-care-exclusive contracts, early
stabilization and appropriate physician-to-physician transfers in
the secondary phase of orthopaedic care are indicated. The orthopaedic trauma
director is also responsible for reviewing and helping to establish
so-called out-of-plan payment arrangements for acute services provided
prior to the onset of problematic compensation issues with panel
members.
Care of the Spine-Injured Patient
A difficult and challenging situation that currently faces the orthopaedic
community is the care of the neurologically impaired spine-injured
patient. The neurosurgical community is now capable of instrumenting the
spine and is willing to provide complete care of the spine-injured
patient without the assistance of orthopaedic surgeons. Hence, neurosurgeons
are taking a more active role in an area traditionally managed by
orthopaedic surgeons. There are now fewer general orthopaedic surgeons
who are interested in and capable of providing spine care in today's
practice environment. Because of this situation, consideration has
been given to changing the on-call program to an every-other-night
schedule, with the neurosurgeon providing coverage for twenty-four
hours followed by the orthopaedic surgeon providing coverage for twenty-four
hours. This coverage would include the treatment of all patients
with spine trauma, regardless of whether they are neurologically
compromised, as well as all patients with low-back pain. It also
would prevent all nonoperative spine care from entering the orthopaedic
arena. If the on-call orthopaedic trauma-panel member were to choose not
to cover the spine, for whatever reason, he or she would be responsible
for obtaining back-up coverage.
Hand Injuries
Most hand injuries associated with trauma can be treated by the on-call
member of the Northern Nevada Orthopaedic Trauma Panel. In the event
of a complex upper-extremity problem, the on-call panel member would
be responsible for obtaining back-up coverage. As in the spine program,
the threshold for consultation would depend on the member's training
and interest in caring for the problem. The call schedule would
be similar to that in the spine program, with coverage alternating
between the orthopaedic surgeon and the plastic surgeon or the general hand
surgeon on a twenty-four-hour basis.
Discipline of Orthopaedic Trauma Panel Members
There may be instances when the Northern Nevada Orthopaedic Trauma
Panel is faced with a disciplinary problem regarding a series of
incidents in which a panel member provided substandard care or a
catastrophic event in which the panel member was negligent by all
standards; such situations require action from a quality-assurance
perspective. There may even be an ethical problem, which can be
more difficult to solve than a breach of care. Although this situation
is rare, the trauma director must be willing to become involved
by appointing a subcommittee to review the case and to offer suggestions
to remedy the situation. Typical courses of action might include
directing the panel member to obtain additional education; working
with a local expert to enhance or update the member's skills; restricting
certain privileges; or, in cases of flagrant misconduct, dismissing
the member from the trauma panel. There also may be peripheral issues,
including legal questions, professional or group bias, personality
conflicts, community politics, and lack of willingness on the part
of the panel member to agree to an improvement program. Occasionally, outside
consultation is required to assist the parties
in conflict resolution; however, with
an equitable trauma director and the
assistance of the orthopaedic quality-assurance subcommittee, most
if not all of these issues should be readily resolved at the local
level. Documentation of all disciplinary actions must be secured
for future reference. Should a legal dispute arise, these activities
are alleged not to
be discoverable as legal evidence as they fall under the umbrella
of the hospital quality-assurance committee12.
Compensation Agreements and Relationship with
Hospital Administration
One of the most important factors in the successful development
and maintenance of an orthopaedic trauma panel is the complete and
unyielding commitment by the hospital administration to the orthopaedic
trauma program. Without the ability to provide compensation to the physician
staff, the high-quality, approved program will fail. It is the national
standard for physicians to be compensated for their commitment to
these types of programs. The requirements of the orthopaedic trauma
program, including travel and meeting time, continuing medical-education
expenses, and on-call responsibilities outside of the general emergency
room, extend well beyond the general hospital practice of orthopaedics.
The important point to stress during negotiation with the hospital administration
is that the hospital is benefiting from the trauma program both
from a business point of view and from the perspective of excellence
in orthopaedic care. The calculated value of the orthopaedic trauma
program to the hospital should include media exposure to high-profile
trauma cases, ongoing staff education programs within the hospital,
teaching of operating-room staff, participation in cost-containment
programs during off hours, surgical cases that are brought to the
hospital for the convenience of the trauma surgeon already working
there, and hospital charges for all orthopaedic reconstruction and
rehabilitation services necessary to support the long-term management
of these types of cases. Placement of an hourly dollar value or
hospital-charge value on these activities results in a substantial
figure that must be considered when discussing compensation programs.
The goal is to create a successful program with the hospital administrator;
if the program fails, the long-term best interest of the trauma
patient will not be served13,14.
The trauma director should be willing to consider the administrative
problems of programs that are in financial trouble and also to
consider adjusting compensation after reviewing the finances with
use of verifiable financial statements. Panel members should also
be considered for compensation bonuses on the basis of cost-savings,
outstanding performance, longevity, and commitment.
What kind of compensation plan works for all parties involved
in the orthopaedic trauma panel relationship? There are several well-described
formulas, including percentages of billable
services, percentages of billable services plus a stipend for the on-call
period, all of the billable services plus the stipend, and the stipend
alone. In general, the orthopaedic traumatologist participating
in a fully certified American College
of Surgeons community program with mandatory performance agreements
should receive at least $1000 ($41.67/hr) for a twenty-four-hour
commitment to trauma care. How the specifics are calculated depends
on the program director, the specific agreement between the physician and
the hospital, and the history of prior agreements regardless of whether
or not they were successful.
The orthopaedic trauma director should receive a stipend for
his or her time and commitment to helping to keep the program accredited,
seeing that training in leadership skills and continuing medical
education are made available, resolving conflicts, and engaging
in public relations efforts on
behalf of the program. Most part-time directors of fully accredited
community programs who have signed performance agreements receive
between $30,000 and $60,000 per year.
Administrative Support for the Trauma Office
The orthopaedic trauma panel deserves administrative support for
the program within the hospital. This probably requires one full-time
employee to assist the director in acquiring data, preparing agendas
for meetings, updating files for panel members, helping the general
trauma staff to prepare for site visits,
selecting cases randomly for quality-
assurance meetings, and acting as a general resource person and liaison
for the orthopaedic trauma program. The orthopaedic trauma director
does not usually occupy an office in the hospital; therefore, the
administrative assistant has a major role in the daily activities
of program management. Although not a level-II requirement, the
trauma office can perform the duties of a research office in the
event that any panel member wishes to engage in outcome studies related
to the orthopaedic program. The School of Medicine at the University
of Nevada, Reno frequently sends students interested in orthopaedics
for clinical rotations; this office can serve as a resource for
students who are interested in pursuing clinical projects. Finally,
the office maintains the official trauma registry and is responsible
for entries, updated information, quality assurance, and site-visit
preparation.
Cost Containment
An unofficial program that has functioned well over the years
is the cost-containment program. This program involves review of a
single category of implant (such as cannulated screws) used for
the treatment of trauma, with conference time allotted to allow corporate
representatives an opportunity to demonstrate new products. The
local representatives are asked to demonstrate their products and
to provide purchasing information for a hands-on review by panel
members. This presentation is followed by a vote of the panel members
regarding desired changes in the inventory. Their decision takes
into consideration surgeon preference,
implant cost and value, and local manufacturer representation in the
community. The purposes of the program are to keep the operating-room
inventory at a manageable, updated level; to satisfy surgeon preference;
to review advances in implant technology; and to demonstrate to
the hospital administration that the orthopaedic trauma panel can
function in a fiscally responsible cost-containment mode. As a result, surgeons
are able to exercise their preferences with regard to implants and
devices, and the hospital is given appropriate direction at a price
that represents a value purchase.
The Northern Nevada Orthopaedic Trauma Panel is a unique blend
of private-practice orthopaedic surgeons functioning within the
Washoe Health System-verified level-II trauma system in Reno, Nevada.
All member practitioners have committed a large portion of their surgical
practice to the care of trauma patients, under a practice agreement
that includes, in part, continuing medical education, quality
assurance, hospital trauma-committee activities, and mentoring of
new members. The director has administrative responsibility for
maintaining the continuity of the panel and assisting in the direction
of programs in outreach,
education, and community awareness. The panel attempts to maintain
cordial working relationships with the hospital administration and
associated trauma services, and it seeks to negotiate reimbursement
programs that emphasize excellence in orthopaedic trauma care. The
program is fully accredited by the American College of Surgeons
Committee on Trauma and has withstood the rigors of that recertification
process. Future developmental issues facing level-II community systems include
electronic advances in outreach programs, ongoing education in trauma
care, cost-containment programs that favor delivering value to
both orthopaedic surgeons and hospital operating rooms, continued
dialogue with health maintenance organizations for fair
reimbursement of professional services, and support of the American
Academy of Orthopaedic Surgeons'
injury-prevention programs. The Northern Nevada Orthopaedic Trauma
Panel can serve as a template for the
design, development, and maintenance of a community trauma system
providing optimal care to the trauma patient.
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