The Northern Nevada Orthopaedic Trauma System was designed and introduced into clinical practice in Reno, Nevada, in 1994. This unique trauma system was first reported in this journal in 2001, in an article presenting the first seven years of the experience1. That report outlined the guidelines for the design, development, implementation, and maintenance of a previously undescribed private-practice orthopaedic trauma panel in a community or rural level-II trauma system. Today, this orthopaedic trauma panel continues to function as an integral part of the Renown Health System (previously Washoe Health System) in Reno, Nevada. This model has served as an example of one type of experience for other interested, developing programs. The program has recently passed the recertification process set forth by the American College of Surgeons Committee on Trauma. In the current update, we review the progress of the program during the past six years as it relates to the mounting pressures on the nation's emergency-department call systems, the program's growth and development opportunities, as well as the newer personnel changes implemented to accommodate the stresses on the hospital-based trauma system in the Northern Nevada referral area.
Mounting Emergency-Department Pressures
It has been well established by the authors of a recent study that this nation continues to confront a crisis in its ability to provide orthopaedic care for the trauma patient2. In 2006, the Trauma Care and On-Call Project Team of the American Academy of Orthopaedic Surgeons (AAOS) cited multiple factors driving this problem, including the increasing number of patients seeking emergency-department care, the reduced number of hospital emergency departments, inadequate funding, and a decreasing number of specialists willing to take call3. Not only does trauma now account for >11% of hospital admissions, but it has become the most expensive category of medical treatment. Emergency-department physicians are clearly concerned. Almost 75% of emergency-department medical directors believe they have inadequate specialist coverage, and 42% think this poses a considerable risk to patient care3. The 2006 AAOS position statement on “On-Call Coverage and Emergency Care Services in Orthopaedics” rallied orthopaedic surgeons to take responsibility in this crisis3,4.
In 2002, the AAOS released a position statement entitled “Emergency Department On-Call Coverage.”2,4 It stated that “in providing emergency department coverage, hospitals should not impose an undue burden on orthopaedic surgeons and other physicians to provide this coverage.” Unfortunately, the number of on-call days was not addressed. It was also recommended that “hospitals compensate orthopaedic surgeons and that payment for these services should reflect the work and liability associated with these services.”4 Since the release of this statement in 2002, liability issues related to the Emergency Medical Treatment and Active Labor Act (EMTALA)5 and hospital bylaws as well as issues related to quality assurance programs have surfaced. In 2005, the memberships of the American Orthopaedic Association (AOA) and the Orthopaedic Trauma Association (OTA) were surveyed with regard to access to emergency-department care2. The response rate was close to 50% from both organizations. Over 80% of the respondents believed that there is a “looming crisis” with regard to patient access to emergent orthopaedic care, and most believed that there is an unstated social contract implicit in the design of medical education for physicians to provide emergency services. Furthermore, most believed that orthopaedic surgeons should be expected to maintain general orthopaedic core competencies.
While it has been estimated that 90% of musculoskeletal emergency conditions can and should be treated at the local community level, patients with uncomplicated, urgent musculoskeletal conditions are being transferred at an increasingly alarming rate to tertiary-care facilities2. In a recent survey by the American College of Emergency Physicians, 66% of the responding emergency departments reported that they had insufficient subspecialty coverage and 33% noted an increase in the annual number of transfers made from one emergency department to another in order to obtain care for their patients2.
In a report by the American College of Surgeons6-8, specific mention was made of the growing reluctance of orthopaedic surgeons to provide emergency-department care as a reason to explore the development of a new specialty: “acute surgery.” It has been reported that this specialty would include the teaching of so-called minor orthopaedic techniques, such as the application of external spanning fixators, placement of traction pins, and closed reduction of certain extremity fractures. The transfer of musculoskeletal trauma care to general surgeons goes against the traditional historic mission of orthopaedic surgery. The 2002 AAOS position statement on on-call coverage4 described the belief that orthopaedic surgeons are the best-trained caregivers to provide emergency musculoskeletal care and that access should be provided twenty-four hours a day, seven days a week. In addition, the position statement stressed that access to specialists in trauma care on a primary or referral basis is vital to patient care, and that all board-certified orthopaedic surgeons should maintain basic emergency-care skills to provide triage care until more severe injuries can be managed by more specialty-focused individuals.
These pressures, along with the EMTALA regulations, hospital bylaw requirements to take call, and the overutilization of emergency departments for primary care by underinsured patients have continued to apply pressure on Northern Nevada's community orthopaedic surgeons as well as those in other similar communities working within organized trauma hospital systems.
Organizational Growth of the Northern Nevada Orthopaedic Trauma Panel
Although the basic trauma-panel system initially described in the 2001 article remains the mainstay of the Northern Nevada Orthopaedic Trauma Panel organization, the program has accommodated the national trends experienced in the Reno community by growing in two major areas: the implementation of an orthopaedic physician assistant program and the addition of a so-called orthopaedic hybrid traumatologist. This new business experiment in hospital trauma care is known as the Reno Hybrid Trauma Model.
In 2005, Renown Health System agreed to explore the possibility of hiring two orthopaedic physician assistants. During stalled trauma-contract negotiations between the physicians and the hospital administration, it was agreed that physician quality-of-life improvement could be used in lieu of higher stipends to keep the negotiation process moving forward. Therefore, two physician assistants were eventually hired with the understanding that the position was new and that practice standards for physician assistants would need to be established. During their training phase, the physician assistants rotated through the general surgery trauma service, the hospital emergency department, and several of the orthopaedic trauma panel members' private offices to learn the specifics of orthopaedic trauma care. This provided all members of the trauma team with an opportunity to meet and greet, gain a level of confidence, and help to establish standards for the new position.
Today, the orthopaedic trauma physician assistants serve not only as an integral part of the orthopaedic trauma team but also as assistants to the trauma nursing staff and therapists, as well as the physicians on call for all of the trauma services. For example, the orthopaedic trauma physician assistants routinely round in the intensive care units, updating staff with regard to mobilization, return-to-surgery plans, splints, and traction. Their main focus, however, is to assist the on-call orthopaedic traumatologist in the emergency department by providing a workup of patients, assisting in surgery, and providing follow-up on issues related to the management of trauma patients. Without residents or interns on the service, these individuals function at a very high level with regard to patient-care responsibilities. These hospital-based employees are currently partially funded by compensation generated from assisting at surgery. Although the data are currently incomplete, it is highly likely that these positions will remain revenue-negative as an isolated service expense. However, when taken in the context of the overall service to the orthopaedic trauma program, which is clearly revenue-positive, these physician assistants are well worth the investment both financially and organizationally as they are valuable assistants to the on-call orthopaedic surgeon staff.
Another area of growth to meet the regional needs of the trauma system has been the development of the hybrid trauma model. This new position was developed (1) to improve the quality of life of the members of the trauma panel whose primary focus is elective orthopaedic practice, and (2) to continue to improve the quality of trauma care within the hospital system.
The hybrid traumatologist position is filled by a subspecialty-trained orthopaedic traumatologist who is employed by a large, private orthopaedic practice committed to the trauma mission at the regional trauma center. This orthopaedic surgeon is a full member of the private practice, yet is assigned to provide daily orthopaedic emergency care at the trauma center. This position does not nurture an outpatient, elective office practice; however, the surgeon has ample time for follow-up care in a private setting. The Reno orthopaedic community has always been opposed to hospital-employed traumatologists as this model is contrary to the private orthopaedic practice model. In general, we have found that a trauma system that invites participation from surgeons from all different practices in town is a powerful negotiating tool. A private-practice traumatologist assigned to work at the local trauma center in this system thus can assist not only members of his or her own group but also the community.
There are several advantages to the hybrid traumatologist. In our system, the traumatologist can practice his or her specialty during daylight hours, can accept the transferred trauma patients from the prior evening without being on call, and can have the security of a private-practice association. In addition, he or she has coverage for personal and professional growth and travel, and subspecialty backup is available for difficult problems such as those involving the hand, spine, and pediatric patients. It can be comforting for a newly trained traumatologist to have senior associates to help on difficult cases and offer their experience with alternative treatment methods in certain circumstances. This allows a surgeon to enjoy the benefits of private practice with solid subspecialty support without being subject to the control of a hospital administration. In addition, the exchange of knowledge and the discussion it engenders among members of the private practice improve care on multiple levels and maintain high levels of interest while upholding high professional standards.
The advantage to the hospital is obvious as well. During the day, the hospital and general trauma service now have a fully qualified orthopaedic traumatologist available for immediate consultation. No longer is the individual who takes call committed to seeing patients or doing elective surgery elsewhere. The urgent surgical cases, daily care, and discharge planning are all performed in a timely fashion, leading to improvements in patient care, reduced in-hospital costs, and decreased lengths of stay. Having the physician on campus, daily, creates an opportunity to develop a strong professional rapport with the orthopaedic physician assistants, the hospital staff, the administration, and the entire trauma team. Finally, time is available to create research opportunities, educational and outreach programs, and real cost-containment reviews.
The advantages to the orthopaedic surgeons in the practice who employ the hybrid traumatologist include better opportunities to develop their elective practices without emergency-room calls and disruptions, the ability to transfer patients for care on the day after call, and, finally, the ability to provide follow-up care for trauma patients that does not interfere with the development of the surgeons' elective practice. The Northern Nevada Trauma System has always prided itself in not transferring patients to other facilities; the hybrid traumatologist helps even further to keep trauma services in the community. This creates improved business relationships by supporting the community trauma hospital and better patient relationships by keeping loved ones in the community.
The trauma panel has also created an implant committee whose mission is to work as a mediator between physicians and the hospital to limit unnecessary variation in implants and orthobiologic usage. At some institutions, these decisions are made by the hospital administrators, and surgeons can use only what is provided. This approach has allowed us to keep some control over the system while allowing concessions on generic items to decrease overall costs.
Another area of growth and improvement between the trauma panel and the hospital administration has been in contract development. General guidelines for reimbursement strategies for professional services provided to patients in the emergency department and for subsequent follow-up procedures were recently reviewed in an AOA Critical Issue symposium by Bosse et al.2.
The Northern Nevada Orthopaedic Trauma Panel members are adequately compensated in the three main areas of work that occur during the twenty-four-hour coverage period. First, the trauma panel members are paid a stipend by the hospital for their twenty-four-hour coverage period. Although we are contractually obligated not to disclose the exact details of the arrangement, the rate is substantially more than that quoted in the 2001 paper. There are ongoing national discussions with regard to how best to determine an appropriate trauma service stipend. A mathematical formula that would include community size, number of trauma admissions, number of trauma operations and consultations, as well as the number and availability of trauma physicians might allow smaller community or rural programs to support a trauma program. Obviously, the larger, busier services would cost more and the smaller rural community expenses would be less. An OTA study currently under way has collected data with regard to stipends, insurance costs, work units, and admissions, among other factors. The stipend has, in general, been considered a payment for the availability of the surgeon for the twenty-four-hour period of service.
In addition to the stipend, the orthopaedic traumatologist is paid a “contact fee” for treating a patient in the emergency department. This contact fee is underwritten by the hospital and is provided to offset the lost physician revenue (i.e., professional services for underinsured patients). Many patients who are treated in the emergency department do not require surgery but do require a closed reduction, suturing, application of a cast, and radiographic review. This subsidy pays trauma physicians for professional services provided to the program.
Finally, all trauma-related surgeries have a guaranteed payment program. The hospital is not in the business of running a billing service for the physicians. The physicians and their offices are solely responsible for billing, coding, and collecting the operative charges. If a patient has any insurance plan—local, state, or national—the hospital subsidy does not apply. If, on the other hand, the patient does not have any funding source, the hospital has agreed to reimburse at 100% of Medicare rates after an agreed-on time frame for orthopaedic procedures (i.e., CPT [Current Procedural Terminology] codes) that include closed treatment, fracture reductions, injections, and surgical interventions.
This negotiated agreement took into account the fact that many out-of-town patients without insurance are sent to the regional trauma center and their care is subsequently assumed by local, private-practice traumatologists. In this system, the follow-up orthopaedic and medical care, such as radiographs, application of a cast, and examinations, are provided by the private offices. Therefore, without some hospital-based financial support, the private offices could not assume this underinsured overhead expense. There are ongoing discussions related to the development of a hospital-based follow-up clinic supervised by the surgeons and staffed by the orthopaedic physician assistants.
In general, hospitals are much more efficient at collecting available funds using expanded corporate resources and access to state and federal support programs. In certain cases, hospital corporations place early liens on client assets and, in general, are much more efficient than the orthopaedic offices at the business of collecting available monies for professional services rendered. The hospitals have been less than willing to share this revenue with private-practice groups. Therefore, this hospital subsidy program levels the playing field between the two trauma partners as it allows the hospital to collect and share in the funding and orthopaedic surgeons to do the work.
With these agreements, the hospital administration and the orthopaedic trauma service can truly partner their relationship to expand the care of the trauma patient. The Renown hospital system has been steadfast in its commitment to support the Northern Nevada Orthopaedic trauma mission. Orthopaedic surgeons can now work without restraint and can care for the difficult cases of these trauma patients without undue worry with regard to the financial burden of time away from the office and the negative impact of assuming enormous overhead expenses of trauma care.
Areas of Growth and Development Opportunity
In 2006, the Committee on Trauma of the American College of Surgeons released a resource document with a list of requirements for the successful provision of orthopaedic trauma care9. This list included items such as emergency operating-room access twenty-four hours a day, seven days a week, and 365 days a year; clinic facilities to follow patients after discharge; research support; and accessibility to implants. In exchange for these resources, the hospital can expect an orthopaedic trauma system to provide direction and leadership with respect to quality assurance, a commitment to limit variation of implant use, and leadership in continuing medical education.
Quality assurance and the time to gather for formal case review in the private-practice trauma system continue to be a difficult and challenging task. Despite the fact that the majority of panel members are willing to participate in open discussions of difficult cases and the occasional poor outcome, some physicians are unwilling to subject their work to healthy peer review. Discipline for mundane occurrences can result in deteriorating relationships among panel membership. Meeting time is another source of personal conflict as most busy orthopaedic surgeons have too many meetings to attend.
Despite hospital and state statutes that offer protection or “assurances” that peer review is protected from discovery in the case of a legal peer-review action against community orthopaedic surgeons, the historical experience in community practices does not support this premise. Physicians who participate in a peer-review process that results in a drastic outcome against another physician such as loss of hospital privileges or other such serious punitive actions can be subjected to a claim, personally, for restraint of trade or public character defamation. There is no policy protection for a personal lawsuit in this legal arena.
With this in mind, the Northern Nevada Orthopaedic Trauma Panel has entered into negotiations with the hospital administration to provide protection from disgruntled physicians in the event of a serious quality-assurance action. This “Indemnity for Persons Assisting in Professional Review Policy” is a contract between the physician and the hospital that is basically an insurance policy protecting the physician against any personal lawsuits or claims that arise from an action by a quality assurance committee. The indemnification must include the complete defense of any claim and must hold the physician on the quality assurance committee harmless from all expense and actions resulting from the claim. This policy should have generic provisions relating to an appropriate hospital peer-review process, participating in the defense of the claim, and allowing the hospital legal team to select and work with legal colleagues on behalf of the orthopaedic surgeon involved in the action. Prior to signing the contract, each trauma panel member should have personal counsel review the policy and his or her corporate medical malpractice carrier should be informed of the contract.
Research and Fellowship Opportunities
It has long been observed in academic orthopaedic discussions that there is an obvious void in the literature with regard to private-practice outcome studies as well as studies related to the demographic and economic data of a community trauma hospital. One area that is in need of study relates to data collection and the publication of information relating to admissions, referral patterns, and procedures of community trauma hospitals and the practice characteristics of participating trauma panel members. This information could be used to determine more appropriately the value of the time that an orthopaedic traumatologist spends away from practice and home. By quantitatively identifying this information, business formulas could be developed to create fair market value for orthopaedic trauma call, stipends, and other reimbursement issues. For example, orthopaedic surgeons in a low-volume, small-overhead practice participating at a rural trauma hospital would not have the same payment program as those at a high-overhead, multispecialty practice who spend several days per week at a large level-I or level-II referral trauma center with research and teaching responsibilities.
Information on orthopaedic trauma procedures, especially from the level-II programs, is also very important for educational purposes. With the volume and types of community-based procedures identified, educational programs sponsored by the AAOS, OTA, and corporations could be established to assist orthopaedic surgeons in practice development. This information could also be used to identify and design community-based trauma fellowships to prepare fellows to enter the private or community-based trauma systems. The educational experience would include not only the surgical experience but also the business and logistical development aspects.
Designated Operating-Room Time for Spine and Hand Procedures
Despite the current recommendation in the resource manual of the American College of Surgeons9 that orthopaedic trauma programs have priority access to operating rooms, many hospitals continue to be deficient in this requirement. Without daytime access to the operating rooms, surgeons and staff are required to operate off-hours, creating unnecessary stress in the system. The hospital administration must realize that a system's commitment to trauma care means that emergent care availability will result in an occasional underutilization of the operating room compared with elective surgical scheduling.
A solution to this conflict can be approached in two ways. First, it is important for the orthopaedic trauma service to monitor how much work is done off-hours and how many times the trauma surgeon is denied access to the operating room during appropriate hours. By collecting and presenting the data, the orthopaedic trauma service will create a need to be addressed by the operating-room committees, administration, and staff. Reports in the literature have demonstrated the benefits of having designated trauma operating rooms, citing the decreased operative times and lower complication rates10. Second, if there is no resolution, the orthopaedic trauma administrator can send the information to the American College of Surgeons review committee to report a program violation, which could jeopardize the hospital certification. Responsibilities in the care of trauma patients, however, should never be used as a bargaining tool for program development.
The development of a strategy to incorporate surgeons who perform elective spine and hand surgery into the trauma program to assist in the care of these complex subspecialty problems continues to be evasive. It has been the guiding principle of the community trauma systems not to allow subspecialty-trained orthopaedists to dismiss themselves from general orthopaedic call on the basis of the inappropriate perception that a year of subspecialty fellowship somehow erases years of general orthopaedic training. The American Board of Orthopaedic Surgery continues to recognize each candidate as an orthopaedic surgeon, and a provision to allow certain individuals to be off-call would leave only a few surgeons to be responsible to care for the many emergent patients, especially on nights and weekends. Many orthopaedic generalists on the trauma panel have agreed to cover call days for these orthopaedic subspecialty physicians in return for the opportunity to assist in surgery on patients with favorable billing codes. Most often, the general orthopaedic trauma physician who is on-call can provide competent first-contact care and then turn the care of the patient over to the subspecialist in the morning. Other options include compensation agreements between orthopaedic trauma physicians and subspecialty orthopaedists or an arrangement of formal backup coverage from the general and/or trauma orthopaedic physician to the on-call orthopaedic subspecialist. Finally, it may become necessary to formally review trauma fellowship curricula as they relate to these problems. Proficiency in the treatment of trauma-related conditions of the hand and operative stabilization of certain traumatic conditions of the spine may be more efficiently handled by the trained traumatologist. In any event, a reasonable solution to this problem continues to be evasive.
Most importantly, orthopaedic surgeons must work together to prevent a professional void with regard to skeletal care; if such a void develops, it will be filled by other willing providers. Historically, the orthopaedic profession has seen skeletal services migrate away from the core purview. Rehabilitation and surgery of the hand, foot, and spine are a few examples. Once again, we believe that it is a formula for failure to begin excluding any staff orthopaedic surgeon from call responsibilities on the basis of his or her practice profile.
In conclusion, the Northern Nevada Orthopaedic Trauma system has experienced the same growing pressures on emergency-care providers that have been described nationally. The system continues to be fully accredited, and it maintains a healthy growth-oriented relationship with the Renown Health System of Reno, Nevada. The business model continues to be a basic contractual relationship between the hospital and the community private-practice orthopaedic surgeons who strive to maintain core competency skills in orthopaedic trauma. The system supports the position statements of the AAOS and the OTA with regard to the commitment to orthopaedic emergency missions, trauma centers, core competencies, education for improvement in system development, and patient care.
The hybrid trauma model, as described, provides distinct advantages to large private-practice groups interested in supporting and participating in regional trauma care and hospital trauma services as well as in providing a controlled professional trauma practice. The position of orthopaedic trauma surgeon should be able to sustain longevity and professional satisfaction without personal burnout. Physician assistants trained in orthopaedics have been developed to function in place of house staff and to offer high-level services both to on-call physicians and to hospital staff in these high-volume trauma centers.
Last, there are research opportunities to better identify business formulas to aid in the additional development of community trauma programs. With continued interest in accurate data collection and reporting, reasonable negotiated solutions among orthopaedic surgeons and hospital administration, and improvement in quality-assurance programs, these organized level-II trauma centers can continue to offer high-quality orthopaedic trauma care to a large percentage of the population.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.