An initiative by midlevel providers to conduct tertiary surveys at a level I trauma center.

INTRODUCTION: Increased patient volume and residents' work hour restrictions have escalated the workload at trauma centers. Because tertiary surveys (TSs) are integral to care, midlevel providers (MLPs) can help streamline this time-consuming process. In this study, we implemented a care plan in which MLPs conduct all TSs, initiate appropriate consultations, and offload residents' work hours. METHODS: From January 2007 to December 2008, we conducted a prospective evaluation of an initiative in which MLPs performed all TSs within 48 hours of admission. A TS consisted of a complete history and physical examination, follow-up of radiologic interpretations, and appropriate consultations. Data included patient demographics, incidence of additional diagnoses noted during TSs and reduction in residents' work hours. Data are presented as mean +/- standard error. RESULTS: During the 2-year period, there were 5,143 patients admitted to the trauma service. The mean age was 36 years +/- 4.8 years, and mean Injury Severity Score (ISS) was 14.2 +/- 4.2. Overall mortality was 5%. Blunt mechanisms accounted for 85%, and penetrating mechanisms resulted in 14% of injuries. MLPs conducted TSs in 56% of patients during the first year and 76% in the second year. In 80 patients (mean age of 44 years +/- 7.1 years, mean Injury Severity Score 21.7 +/- 2.8; p < 0.05 vs. entire cohort), TSs revealed additional injuries, for an incidence of 1.5%. The majority of these diagnoses were of "minor" fractures, half requiring consultations, and 9% necessitating operative intervention. Residents' workload was reduced by 1,802 hours. CONCLUSIONS: Implementation of a MLP initiative to conduct TSs in trauma patients can achieve a consistent and comprehensive workup while offsetting residents' workload and helping to ensure compliance with the 80-hour resident work policy.

Optimal management strategy for incidental findings in trauma patients: an initiative for midlevel providers.

BACKGROUND: Increasing patient volume and residents' work hour restrictions have increased the workload at trauma centers. Further, comprehensive tertiary surveys after initial stabilization and appropriate follow-up plans for incidental findings are time consuming. Midlevel providers (MLP) can help streamline this process. We initiated a care plan in which MLPs conducted all tertiary surveys and coordinated follow-ups for incidental findings. METHODS: From November 2005 through May 2006, we implemented a MLP-driven initiative aimed at performing tertiary surveys within 48 hours of admission on all trauma patients admitted to our Level-1 trauma center. Tertiary surveys consisted of a complete history and physical, radiographic evaluations and appropriate consultations. Incidental findings were recorded and communicated to the trauma attending. A follow-up plan was devised, and the course of action was documented. Patients or family members were informed, and their acknowledgments were filed. Data are presented as mean +/- SE. RESULTS: There were 1,027 patients admitted during the study period. Blunt mechanisms accounted for 81% of the injuries (primarily motor vehicle crashes and falls). Seventy-six patients had 87 incidental findings (7.4%); 53 were men. The mean age was 51.8 years +/- 2.1 years and mean injury severity score was 18.5 +/- 1.4. Incidental findings of clinical significance included 18 pulmonary nodules or neoplasms, 9 adrenal masses (>4 mm), 7 patients with lymphadenopathy, 5 benign cystic lesions, and 3 renal masses. Other neoplastic lesions included bladder (2), thyroid (2), ovary (1), breast (1), and rectum (1). CONCLUSIONS: With prevalent medicolegal pressure and restricted residents' work hours, a MLP-initiative to streamline the tertiary survey effectively addresses incidental findings. This MLP-driven care plan can help reduce residents' workload, provides appropriate follow-up, and minimizes legal risks inherent to incidental findings on the trauma service.