There continues to be controversy over the added value of direct supervision of residents, particularly its effect on patient outcomes. The purpose of this study was to compare direct and indirect resident supervision for the management of blunt spleen injuries and to evaluate differences in patient care.
All patients with blunt splenic injury admitted off hours over a 6.5-year period to a regional level I trauma center were analyzed. Data analyzed included patient demographics, injury characteristics, hospital course, and treatment modality. Direct supervision was defined as the presence of a surgical attending on call in the hospital. Indirect supervision was defined as the surgical attending taking the call from home. Primary analysis consisted of a comparison of outcomes and compliance with a protocol for nonoperative management (NOM) between these groups.
There were 506 total cases, of which 274 (54%) were directly supervised, 157 (31%) had indirect supervision, and 75 (15%) presented when a fellow was the most senior person in house. The mean injury severity score was 21, patients averaged 34 years of age. The splenic salvage rate was 89.7% and the mortality rate was 8.5%. The primary comparison revealed a significantly higher percentage of patients going to operation with direct supervision. Direct supervision was associated with significantly greater protocol compliance for NOM (82% vs 95%; P < .001). Indirect supervision was associated with a greater use of intensive care unit (ICU) resources and protocol noncompliance with the use of splenic artery embolization. The overall success of NOM was 98.6%. Failure of NOM was associated with lack of protocol compliance. Failure of NOM was 9.6% in patients with protocol deviation and 0.3% with protocol adherence. There were no differences in mortality or splenectomy rates between the groups.
This study shows that there were significant differences in the management of blunt splenic injury depending on the type of supervision. Indirect supervision was associated with less compliance with a management protocol, fewer patients undergoing initial operation, more ICU use, increased hospital charges, and a greater use of splenic artery embolization without indication. These results emphasize the value of direct supervision in the management of a select group of trauma patients.
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- In-house versus on-call attending trauma surgeons at comparable level I trauma centers: a prospective study.J Trauma. 1999; 46: 535-540
- In-house trauma attendings: is there a difference?.Am J Surg. 2005; 190: 960-966
- In-house trauma surgeons do not decrease mortality in a level I trauma center.J Trauma. 2002; 53: 494-500
- The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients.J Trauma. 2003; 55: 20-25
- Impact of the in-house trauma surgeon on initial patient care, outcome, and cost.J Trauma. 1997; 42: 490-495
- In-house board-certified surgeons improve outcome for severely injured patients: a comparison of two university centers.J Trauma. 1993; 34: 871-875
- Community hospital level II trauma center outcome.J Trauma. 1992; 32: 336-341
- Limitations of splenic angioembolization in treating blunt splenic injury.J Trauma. 2005; 59: 926-932
- Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms.J Trauma. 1998; 44: 1008-1013
- Splenic embolization revisited: a multicenter review.J Trauma. 2004; 56: 542-547
- Angiography for blunt splenic trauma does not improve the success rate of nonoperative management.J Trauma. 2007; 63: 44-49
- Splenic artery embolization: have we gone too far?.J Trauma. 2006; 61: 541-544
- Angioembolization reduces operative intervention for blunt splenic injury.J Trauma. 2008; 64: 1472-1477
- Improved outcome of adult blunt splenic injury: a cohort analysis.Surgery. 2006; 140: 625-631
- The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience.J Trauma. 2009; 67: 565-572
- Organ injury scaling: spleen and liver (1994 revision).J Trauma. 1995; 38: 323-324
- Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma.J Trauma. 2000; 49: 177-187
- An acute care surgery model improves outcomes in patients with appendicitis.Ann Surg. 2006; 244: 498-504
- Management of acute appendicitis by an acute care surgery service: is operative intervention timely?.J Am Coll Surg. 2008; 207: 43-48
- Impact of acute care surgery on biliary disease.J Am Coll Surg. 2010; 210: 595-601
- Does an acute care surgical model improve the management and outcome of acute cholecystitis?.ANZ J Surg. 2010; 80: 438-442
- Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes.J Trauma. 2002; 52: 420-425
- Trauma faculty and trauma team activation: impact on trauma system function and patient outcome.J Trauma. 1999; 47: 576-581
- Trauma attending in the resuscitation room: does it affect outcome?.Am Surg. 2001; 67: 611-614
- Factors affecting ED length-of-stay in surgical critical care patients.Am J Emerg Med. 1995; 13: 495-500
- Effective triage can ameliorate the deleterious effects of delayed transfer of trauma patients from the emergency department to the ICU.J Am Coll Surg. 2009; 208: 671-678
- Critical care of medical and surgical patients in the ED: length of stay and initiation of intensive care procedures.Am J Emerg Med. 1997; 15: 654-657
Accepted: July 28, 2011
© 2011 Published by Elsevier Inc.