Call, efficiency are among the factors at play for community-based traumatologists

Each year, millions of patients seek care at community-based orthopedic trauma centers across the United States. In these facilities, critically injured patients can have nearly instant access to specialized resources and equipment.

In this issue, Orthopedics Today examines the opportunities and challenges that orthopedic trauma surgeons face as they provide orthopedic care in the community setting.

Unlike their academic hospital counterparts, community hospitals are mainly focused on patient care. There are no medical students, residents or fellows on staff.

“[Hospitals] in the community setting are simple, freestanding hospitals that have only surgeons and ancillary staff like nursing,” Anthony S. Rhorer, MD, director of orthopedic trauma at Scottsdale Healthcare in Scottsdale, Ariz. and founder of Sonoran Orthopaedic Trauma Surgeons, told Orthopedics Today.

Orthopedic trauma surgeons play a pivotal role in providing care in both of these settings. The results achieved by orthopedic traumatologists can yield significant clinical and financial rewards for the hospital, particularly to the community hospital.

“We have studied this intently and published several papers on this topic,” Peter L. Althausen, MD, MBA, clinical assistant professor at the University of Nevada School of Medicine, told Orthopedics Today. Results from Althausen and colleagues’ most recent research showed that fellowship-trained traumatologists at their community-based level 2 trauma system performed the top 20 orthopedic fracture cases in half the time vs. non-trauma surgeons. “This efficiency has significant economic benefits for the hospital and implications in the economics of care for the underinsured patient,” he said.

Adding an orthopedic traumatologist to the staff also benefited the non-trauma partners in Althausen’s practice. “We found that with the addition of a traumatologist, non-trauma existing practices increased 23% in charges and 32% in collections, despite partners taking more vacation days and 14% less call,” he said. These results could be partially attributed to increased non-trauma referrals, full clinic templates and uninterrupted elective operating room schedules. During 2 years, there were increases in elective arthroplasty cases (13.1%), elective arthroscopy cases (35.4%) and total patient office visits (18.8%).

Differences in care delivery

“In an academic setting, the trauma center is going to be largely staffed by learners: medical students, residents and fellows,” Rhorer said. “They are going to be involved in the initial management, evaluation and resuscitation of the patient. Ultimately, the responsibility always lies on the attending surgeons; they are going to have some level of responsibility to be present in one or another at all times.”

Historically, that meant the attending surgeon was just a phone call away, according to Rhorer. “More recently, [attending surgeons] generally are required to be somewhere close by or even with the medical students, residents or fellow, especially if they are operating. They are not allowed to do stuff on their own anymore.”

Community hospitals face many challenges but perhaps the biggest is manpower, Rhorer said. “Trauma is extremely labor intensive, especially for orthopedics,” he said. “We require a lot of hands-on, physical maintenance for the patients; they have dislocations, or they have open fractures. There is manual labor that has to be done to splint the patient in the trauma bay, to evaluate them appropriately, to stay with them during the resuscitation, to follow-up on imaging studies and the laboratory studies and coordinate care of other specialists — neurosurgery, plastic surgery and general surgery.”

In contrast, there are plenty of people available to cover these tasks in the academic setting, although the additional layers of providers means it can take longer to make a decision about care, according to Rhorer. “There is a delay from the initial evaluation of the patient to the actual decision making that is being done primarily by the senior staff member or attending surgeon.”

Those kinds of delays are not an issue in Rhorer’s hospital. “I work in a community trauma setting, where when I get a phone call from a general surgeon, and they tell me there is a patient with a pelvic fracture and an open tibia fracture and a closed head injury, I can work on my computer from home and look at all of the X-rays. I have already got an idea of what we are going to do. I can call the operating room, and I can have a plan before I even pull out of my driveway.”

Getting operating room access can be an issue in many hospitals. “Operating room access is a universal problem, whether it is community or academic,” Rhorer said.

“The operating room in a hospital is generally, quite frankly, the ATM of the hospital,” Rhorer said. “If the operating room is not functioning efficiently, and it is not doing the right kinds of cases to bring money to keep the rest of the wheels turning in the rest of the facility, then that is a problem.”

All types of hospitals, from academic centers, to county hospitals, to for-profit community trauma centers, have the same problem, Rhorer said. “They want the operating rooms to always be doing the best cases at the best time possible. Usually the specialty that suffers the most is the specialty that brings in the least amount of money, which is going to be indigent care/trauma.”

Not every hospital has an issue with OR access, though. “At our facility, we follow the guidelines of the AAOS/OTA [American Academy of Orthopaedic Surgeons/Orthopaedic Trauma Association] position statement to have a dedicated orthopedic trauma room 24/7 with support personnel,” Althausen said. “Anesthesia is also provided by private practitioners who are motivated by efficiency and quick turnover times. The hospital also provides physician assistants for the orthopedic trauma service to help with floor care, paperwork and surgical assistance when needed.”

Their current study on trauma room access in academic and community-based systems has revealed some shocking results: Some teaching hospitals do not have trauma rooms, Althausen said. “This is not a unique problem for community systems, but one solved by strong negotiation and good lines of communication between physicians and administrators,” he said.

The ACA may affect orthopedic trauma care, although to what extent remains unclear.

“I do not think anybody knows what the Affordable Care Act is going to do, exactly,” said Cory A. Collinge, MD, an orthopedic surgeon specializing in adult post-traumatic reconstruction and orthopedic trauma, in Fort Worth, Texas. “Ultimately, I think that reimbursement will go down,” Collinge told Orthopedics Today. “In trauma, though, [some of] the unfunded patients may become funded.”

However, with less than 3% of the U.S. population currently signed up for the ACA, surgeons should not depend on the government program to solve the problem of uninsured and underinsured patients, according to Althausen. Instead, all traumatologists must practice the highest quality, most financially responsible care, which means examining procedures and cutting costs without sacrificing patient care.

“Standardizing drapes and order sets, getting rid of implant representatives to decrease upselling and implant costs and agreeing to postoperative protocols will all dramatically reduce trauma health care expenditures,” Althausen said. “The initiation of the Balanced Care Payment Initiative has the most promise for shifting the balance in favor of the surgeon if all members agree to work as a team and agree to standardized treatment protocols for cost containment.”

Trauma call

There was a time when taking call was an expected part of being on staff at a hospital, said Roy W. Sanders, MD, director of the Orthopaedic Trauma Service, in Tampa, Fla. “It was not incentivized; it was a requirement,” he said. “The complexities of injuries have gotten so great now because of high-speed car accidents and falls that not everybody wants to take call; they do not feel comfortable taking it.”

As a result, hospitals have had to find ways to entice general orthopedic surgeons to take call. In general, hospitals follow two models to incentivize surgeons to take call. In one model, the surgeons receive a per diem rate, which can range from $500 to $1500, depending on the level of acuity of the hospital and bill the patient’s insurance directly, Sanders, who is the Trauma Section Editor of Orthopedics Today, said. According to the second model, the fee is smaller, maybe $500, but in addition to billing insurance in funded cases, the hospital will reimburse the surgeon Medicare rates for the indigent cases, he said.

Althausen’s hospital offers a “favorable” call stipend and trauma call agreement. “As a result, call is sought after by many non-trauma trained orthopedic surgeons in the community,” he said. “The system now runs well and is supported by the hospital from both a systems and financial perspective.”

Collinge said the two full-time, fellowship-trained orthopedic trauma surgeons and the five or six community surgeons who take call at his hospital are “financially incentivized by a call stipend, and I think they are self-incentivized by their interest in trauma.”

Reasonable call schedule

Developing a reasonable call schedule depends on the hospital, the type of trauma typically encountered in the hospital and on surgeon preference. “We get a lot of daytime trauma — a lot of ranching injuries, a lot of blunt trauma, not so much penetrating trauma … which is also nice for lifestyle,” Collinge said.

Althausen and colleagues have a system where all-day trauma call is covered by fellowship-trained traumatologists and night call is shared by all members of the trauma panel. “Emergent cases are done by all call takers at night, while nonemergent cases are put on for the daytime traumatologist in a dedicated operating room the following day,” he said.

The traumatologists take call between five and eight nights a month; non-trauma partners cover the rest, according to Althausen. At least one traumatologist is always available for phone consultations when not on call and can come to the hospital if emergencies occur. “In addition, it is not unusual for a traumatologist to call in a nontrauma colleague for a complex foot injury or mangled hand,” he said. “The system works both ways.”

Daytime call coverage has allowed community surgeons to run full-elective clinics and operating rooms during the day. “Nighttime call duties now primarily consist of triage and the occasional emergency,” Althausen said.

Rhorer said he is most comfortable being on call six or seven nights a month. “I take more call than that, I do not want to, but I have to,” he said.

Avoiding burnout

Given the demands of being an orthopedic trauma surgeon, such as long hours and a stressful environment, burnout can almost seem inevitable. For Collinge, adding a trauma partner was the answer. “The more bodies, or the more fellowship-trained guys that are around [the better],” Collinge said. “I added a trauma partner last year and that is the best thing I ever did. He is excellent. We talk about cases and what is going on in the orthopedic trauma world. He takes half of the difficult cases and does a nice job of it.”

Working in a busy trauma center with more than 96,000 emergency department visits per year, burnout is a constant threat, Althausen said. “The philosophy of our program — that trauma surgeons are not just ‘call takers’ — has really helped avoid this,” he said. “All our nontrauma partners share in the nighttime call responsibility, allowing for reasonable call duties. From an economic and safety perspective, efficient daytime operative care is best for all parties involved.” Hospitals or health systems must hire enough personnel to spread out physician responsibilities, which allow surgeons to take vacations, spend time with their families, pursue recreational activities and perform research.

For Rhorer, the best way to avoid burnout is to spend time with his family and to immerse himself in activities outside the hospital.

Maintaining expertise level

Although it may be a challenge to do so, given schedule constraints, orthopedic trauma surgeons must take steps to maintain their level of expertise. The first step is to pursue continuing medical education (CME), which is required to maintain certification with the American Board of Orthopaedic Surgery, Rhorer said. That involves attending trauma courses to stay abreast of new technology and surgical procedures. Second, is to maintain an appropriate volume of cases.

“Trauma surgeons who are working in trauma centers where they have low volume are at risk for diminishing capabilities for handling multiply injured patients and complex periarticular fractures and fractures of the pelvis and acetabulum.”

In addition to attending trauma CMEs, for which Althausen’s hospital provides an educational fund, the fellowship-trained traumatologists are instructors at various trauma courses from the OTA, the AO Foundation and the AAOS.

“Our program also has a quarterly M&M [morbidity and mortality] meeting, where we have formal case presentations and discussion on trauma issues and complex cases,” Althausen said. “We also host an orthopedic journal club open to all members of the orthopedic community, with guest speakers on new techniques and updates on trauma care.”

Ways to improve trauma care

“Having more fellowship-trained surgeons across all orthopedic specialties in every community raises the bar for the trauma patient and allows care to equal or surpass that of many academic institutions,” Althausen said. “Adherence to well-developed protocols for life-threatening conditions such as pelvis and acetabular fractures, shock, compartment syndrome and deep vein thrombosis prophylaxis are extremely important. Having an indemnified, working M&M and quality assurance program is mandatory to uphold standards of care, continue educational objectives and weed out the dangerous surgeon.

“It is also incumbent that a community-based traumatologist be actively involved in research involving outcomes and economic issues affecting community-based trauma systems,” Althausen continued. This type of attention reveals the strengths and weaknesses of community-based trauma care and ultimately, leads to better care.

Finally, the ever-increasing cost pressures on hospitals means that surgeons must not only be aware of costs and the financial impact of their treatment decisions but also how to control them to help their institutions remain financially viable, according to Althausen.

Sanders thinks surgeons at level 2 centers should have greater autonomy when it comes to sending patients to a level 1 institution. “The patients should come first and there should be more trauma-trained orthopedists at these level 2 [centers].”

Proliferation of trauma centers

The data show that trauma centers are effective, providing excellent health care to some the nation’s most gravely injured patients. That success has led to a major problem for both hospitals and orthopedic trauma surgeons: the proliferation of trauma centers. “We have a real crisis in the United States right now where hospitals have recognized that there is money to be made off of trauma,” Rhorer said. “There has been this massive proliferation of trauma centers. Basically, hospitals are kind of going crazy trying to build trauma centers all over the place and staff them with newly trained orthopedic trauma surgeons. It is diluting the experience.”

Recent research from JJ Tepas III and colleagues showed that this rapid expansion can have a direct effect on the cost of trauma care. They examined what happened when a level 2 trauma center was activated in an established trauma region with an existing level 1 center without an obvious need for another center. Their analysis demonstrated that the addition of a new trauma center increase personnel costs by 217% and decreased the volume of injuries required for training and education.

“[This] is going to have to be addressed in short-term because we have taken what was a functional trauma center system in the country, and we have capitalized on it, and we are now de facto destroying it for profit,” Rhorer said. – by Colleen Owens

Is the explosion of level 2 hospitals opening across the United States a community requirement or a financial incentive?

Financial incentives drive surge

The explosion of level 2 trauma centers opening across the United States is due to control of patient populations and financial incentive. We should pay attention to this trend. It can affect our future as orthopedic trauma surgeons and more importantly, patient care and long-term trauma costs to insurers and society. Some established level 2 trauma centers, that have no competing level 1 centers nearby, such as those in Reno, Nev., under the direction of Tim Bray, are a model for a well-organized system.

What is different now is the explosion of level 2 trauma centers in major metropolitan areas, which are superfluous, and in direct competition with established level 1 trauma centers. This recent increase by certain parent organizations or systems is the concern. The literature supports increased survival rates in severely injured patients treated at a level 1 trauma center with appropriate resources and corresponding resuscitation. In addition, with level 1 American College of Surgeons accreditation, close review of facilities, staff and outcomes is generated to create quality control.

The increase in level 2 centers is partly made possible by the increasing number of orthopedic traumatologists we are training. With more than 70 new fellows coming out of fellowship annually and hiring of foreign surgeons with an H1 Visa, these centers are easier to staff. There are a lot more traumatologists looking for jobs as fracture surgeons instead of traumatologists. In addition, the increase in level 2 trauma centers can affect — and is affecting — the volume at level 1 trauma centers. This in turn can cause far-reaching implications such as increased duplicated costs and resources for society. In addition, residents have less exposure to cases, outcomes may not be as good with lower volumes and less specialized surgeons, and ultimately there may be expanding of surgical indications to maintain volume.

Why the increase in these centers? We have the availability of orthopedic traumatologists to staff them appropriately. A well-run orthopedic trauma service can be best for patient care, outcomes, and cost containment. Let us stand up and take charge of the situation before it is too late.

Lisa K. Cannada is an associate professor in the department of orthopedic surgery at Saint Louis University in St. Louis and an Orthopedics Today Editorial Board member.
Disclosure: Cannada has no relevant financial disclosures.

Level 2 trauma centers have problems

As public funding has increased for trauma services, many hospitals realized that being a level 2 trauma center was the way to go. The only limitation was personnel. As money flowed, hospitals were able to offer better incomes and resources to orthopedic surgeons wanting to do trauma. During the last decade, orthopedic trauma fellowships have increased precipitously to where more than 70 fellows are released per year; only a portion receive the necessary training. With more fellows available, hospitals have been able to “check off the box” for orthopedic trauma.

Suddenly, there were level 2 centers sprouting up everywhere. Some physicians feel they are needed for underserved communities (both urban and rural), while others feel they are financially driven and hurt the safety net level 1 trauma centers in their same catchment area. The reality is that it is not such a simple issue of wrong or right.

Level designation does not always reflect the volume and quality of services provided. My co-authors and I wrote an article in the early 2000s about how about the level of services was not consistent among level 1 centers. A leading trauma journal turned it down, but a peer-reviewed journal on patient safety accepted it. It was not politically correct to insinuate that our system lacked regulatory consistency and that politics or money may have something to do with being able to call yourself a trauma center. The trauma center designation does not adhere to strict guidelines like the Federal Aviation Administration, Federal Communications Commission or other public safety commissions. Getting designated is voluntary, and there is little homogeneity or validation except for the efforts of the American College of Surgeons (ACS), who apply some method and process by which hospitals are judged. But even they must be careful, since a trauma center in a critical needs area that gets hit too hard will lose what little funding or resources they have to provide care. The reality is that depending on the state, hospitals can self-designate, or get state verification or invite the college for a verification visit, which is not binding. Thus, a well-functioning, ACS-verified level 2 hospital can outperform a dysfunctional self- or state-designated level 1 hospital. Unfortunately, there are no binding regulatory bodies that determine if a hospital is a suitable trauma center, and recent outcome reports show that some level 2 centers do a better job than some level 1 centers.

As they say in politics and business, if you “just follow the money” you will usually find out who and what is happening. We now have a poorly regulated market; with an abundance of orthopedic fellows (supply); with hospitals that get money (sometimes lots of if) for providing trauma (demand). It is no surprise that trauma centers are sprouting up. What is interesting is where they decide to do so.

What some profiteering hospitals did was truly a lesson in market strategy. It appears as if they looked at zip codes with a good demographic, which means insured patients. Then, they decided to set up shop as a trauma hospital in those areas and intercept trauma traffic that previously went to the level 1 center. The level 2 systems would populate their staff with good surgeons and a “good enough” system to pass the cursory scrutiny required by law. Some were brave enough to ask the ACS to come and visit, and in their defense, many were good enough to be a level 2 trauma center. The effect was what has previously been mention in the preceding articles. Level 1 centers saw less volume, and the volume they kept was a bad payer mix, which stresses their economics even further. The level 2 centers that were for profit did not have to re-invest their earnings back into becoming a better trauma center, so they just remained barely “good enough” in many cases, and the money was shuffled from the hospitals that needed the money to the shareholders. This has happened in several states and resulted in a lot of contentious discussion and even legal action.

My personal belief is that the lack of regulation and consistent methods of trauma center evaluations (ACS vs. state vs. self), and the flow of funds is the root cause of the issue. I also do not think we need level 3 or level 4 hospitals any longer.

If I were to design a system, it would be more like the one in Maryland that has mandatory rules and regions that function autonomously and feed into appropriate centers. Level 2 centers would be the rural centers that provide nearly the same care as level 1 centers, and level 1 centers would partner with level 2 centers and allow patients that get flown 50 miles to a city to be quickly stabilized and transferred back to an accepting and competent provider closer to their homes.

As long as there is no control oversight of the river of money that flows, we will continue to have the current problems. In the end, quality is questionable and patients are fooled. It is the ugly gorilla in the room that nobody wants to touch.

Bruce H. Ziran, MD, FACS, is director of Orthopaedic Trauma at The Hughston Clinic at Gwinnett Medical Center.
Disclosure: Ziran is on the publications editorial/governing board for Clinical Orthopaedics and Related Research, Journal of Bone and Joint Surgery, Journal of Orthopaedics and Traumatology, Journal of Trauma, Patient Safety in Surgery; and is a board member/has committee appointments for the AAOS, ACS, Orthopaedic Trauma Association and American Board of Orthopaedic Surgery Inc.