Background
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.
Methods
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.
Results
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.
Conclusion
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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Article info
Publication history
Accepted:
July 28,
2011
Identification
Copyright
© 2011 Published by Elsevier Inc.
