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In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis
Alexander C J de la Mar1, Robin D Lokerman, Job F Waalwijk
1From the Department of Surgery (A.C.J.d.l.M., R.D.L., J.F.W., Y.O., Q.M.J.v.d.V., F.H., R.M.H., M.v.H., L.P.H.L.), University Medical Center Utrecht, Utrecht; Department of Clinical Epidemiology (Y.O.), Leiden University Medical Center, Leiden; and Department of Surgery (M.v.H.), Diakonessenhuis, Zeist, Doorn, Utrecht, the Netherlands.
Background:
A rapid trauma response is essential to provide optimal care for severely injured patients. However, it is currently unclear if the presence of an in-house trauma surgeon affects this response during call and influences outcomes. This study compares in-hospital mortality and process-related outcomes of trauma patients treated by a 24/7 in-house versus an on-call trauma surgeon.
Methods:
PubMed/Medline, Embase, and CENTRAL databases were searched on the first of November 2020. All studies comparing patients treated by a 24/7 in-house versus an on-call trauma surgeon were considered eligible for inclusion. A meta-analysis of mortality rates including all severely injured patients (i.e., Injury Severity Score of ≥16) was performed. Random-effect models were used to pool mortality rates, reported as risk ratios. The main outcome measure was in-hospital mortality. Process-related outcomes were chosen as secondary outcome measures.
Results:
In total, 16 observational studies, combining 64,337 trauma patients, were included. The meta-analysis included 8 studies, comprising 7,490 severely injured patients. A significant reduction in mortality rate was found in patients treated in the 24/7 in-house trauma surgeon group compared with patients treated in the on-call trauma surgeon group (risk ratio, 0.86; 95% confidence interval, 0.78-0.95; p = 0.002; I2 = 0%). In 10 of 16 studies, at least 1 process-related outcome improved after the in-house trauma surgeon policy was implemented.
Conclusion:
A 24/7 in-house trauma surgeon policy is associated with reduced mortality rates for severely injured patients treated at level I trauma centers. In addition, presence of an in-house trauma surgeon during call may improve process-related outcomes. This review recommends implementation of a 24/7 in-house attending trauma surgeon at level I trauma centers. However, the final decision on attendance policy might depend on center and region-specific conditions.
Level Of Evidence:
Systematic review/meta-analysis, level III.
