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for IH attending coverage.10 If upper-level internal medicine residents can effectively run the medicine ICU overnight, upper-level surgical residents should be able to manage the surgical ICU overnight without IH attendings. Another proposed factor in trauma patient care is attending surgeon time to bedside. Previous studies show that as long as attendings arrived at bedside within a set time (10 to 15 minutes), the outcomes were equal.3,9 After implementation of the ACS COT time mandate, this was validated by Tinkoff and colleagues.11 In our study, attending presence within 15 minutes increased by 36.6% for TAR. Despite this increase, outcomes remained unchanged for the most severely injured patients. Although not the primary goal of this study, these data question the ACS COT time mandate and suggest the need for additional discussion. The prevention of “never” events has been used as another justification for IH attending coverage. Durham and colleagues7 described a substantial reduction in preventable deaths with IH coverage, from 8.1% to 1.0%. However, this statistic evaluated 10,000 patients, there are obvious limitations. First, these are retrospective data. On this topic, there is only 1 prospective article and 1 randomized controlled trial, both showing no difference in mortality.9,10 Second, this study takes place in a mature trauma center with upper-level residents on-call in-house 24 hours per day that respond to trauma alerts and are in direct contact with attending physicians. There are well-organized protocol for clinical care and communication with attendings. Although this study might not be generalizable, it should be applicable to similar university-based Level I centers.

CONCLUSIONS The only positive effect of IH attending presence was improved time from ED to OR for the highest level of alert. There was no improvement in survival, even for the most severely injured patients. In addition, timely attending presence at bedside did not change patient outcomes. In-house attending coverage has implications for

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residency training and graded levels of supervision. This study raises serious questions about the necessity of IH attending coverage and the ACS COT time mandate for the highest level of alerts. Author Contributions Study conception and design: Cox, Kearney Acquisition of data: Cox, Davenport, Kearney Analysis and interpretation of data: Bernard, Bottiggi, Chang, Talley, Kearney Drafting of manuscript: Cox, Kearney Critical revision: Cox, Bernard, Bottiggi, Chang, Talley, Tucker, Kearney REFERENCES 1. Arbabi S, Jurkovich GJ, Rivara FP, et al. Patient outcomes in academic medical centers: influence of fellowship programs and in-house on-call attending surgeon. Arch Surg 2003; 138:47e51. 2. Rogers FB, Simons R, Hoyt DB, et al. In-house board-certified surgeons improve outcome for severely injured patients: a comparison of two university centers. J Trauma 1993;34: 871e875. 3. Fulda GJ, Tinkoff GH, Giberson F, Rhodes M. In-house trauma surgeons do not decrease mortality in a level I trauma center. J Trauma 2002;53:494e500. 4. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. 2005. Chicago, IL: American College of Surgeons; 2006. 5. Claridge JA, Carter JW, McCoy AM, Malangoni MA. Inhouse direct supervision by an attending is associated with differences in the care of patients with a blunt splenic injury. Surgery 2011;150:718e726. 6. Helling TS, Nelson PW, Shook JW, et al. The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients. J Trauma 2003; 55:20e25. 7. Durham R, Shapiro D, Flint L. In-house trauma attendings: is there a difference? Am J Surg 2005;190:960e966. 8. Luchette F, Kelly B, Davis K, et al. Impact of the in-house trauma surgeon on initial patient care, outcome, and cost. J Trauma 1997;42:490e495. 9. Demarest GB, Scannell G, Sanchez K, et al. In-house versus on-call attending trauma surgeons at comparable level I trauma centers: a prospective study. J Trauma 1999;46: 535e540. 10. Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med 2013;368:2201e2209. 11. Tinkoff GH, O’Connor RE. Validation of new trauma triage rules for trauma attending response to the emergency department. J Trauma 2002;52:1153e1158.

Discussion DR DONALD BARKER (Chattanooga, TN): I think Dr Kearney and his colleagues have done something that we’ve been trained to do, which is take just sort of standard dogma and look at it again

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and again in different ways and in different situations and see if we can come up with an answer out of that milieu of different types of data assessment. This is an important study because it challenges the status quo. And I think that’s something that we probably need to do. They asked the question whether having an attending trauma surgeon in house vs an attending trauma surgeon out of the house really made a difference in the patient care. And, essentially, I think what they did ask was, is the mandatory 15-minute arrival of the trauma surgeon in the trauma bay as significant a factor in generating a positive outcome as it is to have the attending maybe use a little bit of judgment as to when they need to show up or not. One of the key things to keep in mind is that this study was performed in a well-established, nonurban trauma center. This program has been in place for 20 years and has had plenty of time to develop protocols and to develop institutional judgment and wisdom in relation to the care of trauma patients. The patients are primarily blunt trauma patients. There may be a lot of head injuries in these, and there’s really not a lot you can do for them. There are also a lot of blunt chest injuries and abdomen injuries, for which the attending really may be helpful, not in the initial 15 minutes, but in the decision about which test to get, which test not to get, which unit the patient goes to, how sick the patient really is, and provide some judgment in that. So the ongoing presence of the attending is important but may not be as important in that 15 minutes in a well-established trauma center with a trauma team with senior folks as it is in taking care of these patients after that 15-minute period of time. During the whole time this study was ongoing, there was a dedicated trauma faculty. There was a dedicated trauma faculty before the in-house call took place. And, again, the trauma team was experienced, with nurses that had been there for a long time, their various support personnel, and with immediate access to ICUs, operating rooms, etc. So this setting may not be applicable to other settings. I don’t think you could take this to a start-up program and get the same results or maybe not even to a program that sees a preponderance of penetrating trauma. In this particular study, it really did not affect the major outcome variable, which is mortality. However, the presence of the attending did seem to affect the length of hospital stays, ICUs, emergency department stays, etc. So maybe we are relevant in some way in doing some of these things. But we may have other values because most of us now not only do trauma but acute care surgery. To really be honest with you, most of my time in the hospital is spent taking care of acute care surgery patients. I think the decision-making is fairly complex in these patients, maybe more complex than it is in the trauma patients. There are also administrative issues, and there’s also that fact that you’ve got a senior surgeon in house to provide some backup, answer questions, and provide some ongoing education. I have 2 questions. How many alerts were initiated from field personnel? Those can be fairly inaccurate because they don’t have all of the information to initiate a proper level of alert. Was there anything special about the training of the team? We saw the composition. How are these people trained to take care of these patients? Did you include emergency department deaths in this?

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It does look like fewer patients went to the operating room, and you explained that, but maybe the attending can say, “Maybe we don’t need to operate on that one, maybe we should watch that one instead of go to the operating room.” I think you have a real opportunity at some point to take the group of patients that you had in the out-of-house call era, and you had almost a 50-50 group of patients, and compare the ones for whom the attending was there during the 15 minutes with the group that had no attending there. So you have another data set that you can look at that may be very helpful. I think you should be complimented, though, in changing your attending response time to the emergency room to under 15 minutes from around 50% up to almost 80%. That is an incredible amount of work and shows an incredible amount of dedication. DR JEFFREY YOUNG (Charlottesville, VA): As Dr Barker said, this is an excellent study in that the center is very, very mature, has excellent care processes, and is known to provide good care. In their trauma care environment, the variable of the in-house coverage during this time period was, as best as they could do it, an isolated variable because many of the other aspects of their trauma care system stayed the same. In a previous study, it was found that the in-house attending, possibly in demonstrating his or her self-worth, was found to have bypassed many of the trauma care protocols at the bedside, saying that, based on the physical examination, the patient didn’t need CT and L spines, didn’t need a CT, etc. And that one study found that there were adverse outcomes because of that, the care was delayed, and all of that care needed to be repeated a day later when everybody looked at it and realized what had been missed. Did you find any instances of that? Although the Injury Severity Scores were similar, the percent sent to the ICU increased. And I’d like to know if that was specific to any particular type of patient, and maybe your own theories about why that would be, whether it was head injuries, or complex, or orthopaedic, etc. The most important outcome, survival, is not affected by in-house attending. Because many of these studies, including those at the University of California, Virginia Commonwealth University, and your own, are occurring at mature level 1 centers, do you think the findings could be explained by the fact that your care systems over-ride individuals? A former mentor of mine described these as wizard systems, that if you can figure out the right thing to do to the patient only when the wizard’s there, if the wizard’s not there, then you can’t figure out what to do. I think that in many of these studies, the systems are designed in such a way that the wizard is not necessary. And I think that’s probably the way it is in your center and many other mature level 1 centers that I have visited. Do you think that in mature systems, the attending at the bedside may not be as important, but the attending may be very important at immature systems, such as level 2 and level 3 centers? And would you think from what you’ve found that perhaps we have it a little bit wrong, that the attending would need to be in house at busy level 2s and not in mature level 1s? DR RON STEWART (San Antonio, TX): First, I compliment you on a great presentation and for building the trauma system at UK.

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It’s very impressive. Given the maturity of the system and the complexity that Dr Young just laid out, it seems to me that fundamentally this study, even though it’s a good, natural experiment, is really underpowered, because you’ve already made a lot of improvements in care. And mortality in that context is a really difficult endpoint. If I looked at it, I would say there’s a trend toward mortality. And I would read sort of the opposite conclusions, that there were many system improvements that cumulatively, over time, may actually make a difference in mortality. Please comment on that. DR BRENT EASTMAN (San Diego, CA): I congratulate the authors for using evidence to really address one of the sacred cows of The Committee on Trauma of the American College of Surgeons. Having trained in the era of eminence-based medicine as opposed to evidence-based medicine, I have made that transition. I do have 1 question, about 1 variable that you didn’t address, which may be the elephant in the room. When you say in-house attendings, we know that all surgeons are not created equal and all people forced to be in house by these regulations may be surgeons who aren’t particularly interested in trauma or it may not be their specialty. I doubt that’s the case in your well-established trauma center, but I think it would be in others. Therefore, I think we have to look at the competence and training of those we require to be in the house. DR MICHAEL HAWKINS (Augusta, GA): I’m curious, based on your results, if your practice group or your hospital is going to want to continue paying for in-house call. DR DAVID FELICIANO (Indianapolis, IN): This is a centerspecific study. If one looks at urban trauma centers, 30% of the admissions have penetrating trauma and 25% of the abdominal gunshot wounds involve named vascular structures. Having an experienced attending surgeon across the table from a chief resident is a significant improvement as compared to a junior surgical resident when the abdominal aorta has a large hole in it, and I ask whether you accept the limitation that this study is specific for your center, but not all. DR PAUL A KEARNEY: The answer to the question about trauma alerts that Dr Barker raised is that we do allow our field teams to call trauma alert reds. Most of them are called from the field, but many are modified by physiologic criteria that they send to us and then we can call the alert. So I think there is some overcall, but that’s what you want in any mature system. You do want overtriage. We do not include DOA. So if you showed up dead and you stayed dead, you weren’t in these numbers.

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Regarding the questions that Dr Young asked, we did not specifically look at the number of studies and how they were applied. It’s been said that the attendings may be able to modulate the number of diagnostic studies that get used. We did not specifically look at that in this study. And we certainly have the power to do so and could come back in another data set and look at that. I think, in mature systems with senior level residentsdand I’m going to address Dr Feliciano’s question here toodin our place, the residents rotate on the trauma and the acute care surgery service every year. It’s the only service they do all 5 years. They are all Advanced Trauma Life Support certified. By the time they get to their chief year, most of them are very comfortable resuscitating critically ill patients. And some of our more polished senior and fourth-year residents are as competent as some of the attendings. In this mature system, the in-house attending adds very little. I would agree with Dr Feliciano’s point. We have mostly blunt trauma. I’m not so sure that these data really translate to a large urban center where you are hauling patients who are bleeding to death to the operating room. This then becomes a surgical skill set rather than management of nonoperative blunt trauma. I trained in an era in which we did not have attendings coming in at night for trauma. By the time I got to my young faculty position, all of us were coming for operative events. That is a paradigm shift that occurred over my professional career. I think wizards are more important in level 2 and level 3 centers, where not everybody knows what to do. I am not sure that the attending adds anything in a mature level 1 center. The point here is that it doesn’t matter where you sleep as long as you have timely notification, good communication etiquette, and good protocols for calling the attending physician. I think these are the more important things. Much of what Dr Stewart said is true. This really is a maturation process. Fully mature trauma centers with resident training program in surgery do not require in-house attending coverage. The study is not underpowered. We have plenty of power in this to detect the differences here. Process improvement is at the core of our practice. This was a well-designed natural experiment. Putting the attendings in the house did not improve outcomes. It cost the hospital a bunch of money. All of our in-house surgeons, with the exception of one, have completed trauma fellowships and are board certified in surgical critical care. The exception trained in a very good program at University of Tennessee Chattanooga, and he is excellent.

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