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The Delivery of Critical Care Services in US Trauma Centers: Is the Standard Being Met?

Nathens, Avery B. MD, PhD, MPH; Maier, Ronald V. MD; Jurkovich, Gregory J. MD; Monary, Daphne; Rivara, Frederick P. MD, MPH; Mackenzie, Ellen J. PhD

The Journal of Trauma: Injury, Infection, and Critical Care: April 2006 - Volume 60 - Issue 4 - p 773-784
doi: 10.1097/01.ta.0000196669.74076.50
Original Articles
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Background: Although there is substantial evidence supporting the benefits of an intensivist model of critical care delivery, the extent to which this model has been adopted by trauma centers across the United States is unknown. We set out to evaluate how critical care is delivered in Level I and II trauma centers and the extent to which these centers implement evidence-based patient care practices known to improve outcome.

Methods: All Level I and Level II trauma centers in the United States were surveyed using a previously validated questionnaire pertaining to the organizational characteristics of critical care units. Questions identifying the impediments to the implementation of an intensivist model of critical care delivery were added to the original survey. An intensivist model intensive care unit (ICU) was defined as one meeting all of the following criteria: a) the physician director was board certified in critical care; b) >50% of physicians responsible for care were board certified in critical care; c) an intensivist made daily rounds on the patients; and d) an intensive care team had the authority to write orders on the patients. The survey respondents were also queried regarding the extent to which they complied with evidence-based guidelines for care in the ICU.

Results: The overall response rate was 65% (295 centers). Only 61% of Level I centers and 22% of Level II centers provided an intensivist model of critical care delivery. Sixty-nine percent of centers had a form of collaborative care with an intensivist, but few centers had dedicated intensivists without responsibilities outside the ICU. The most common reason cited for not involving an intensivist in the delivery of critical care services was a concern regarding a loss of continuity of care. There was limited implementation of evidence-based practices in the ICU; the model of critical care delivery had no effect on rates of implementation of these practices.

Conclusion: The process of trauma center verification and designation should assure a high quality of trauma care. In keeping with these expectations of quality, the delivery of critical care services in trauma centers should evolve to a model that both includes the trauma surgeon in the care of the injured and allows for collaboration with a dedicated intensivist, who may or may not be a surgeon. The benefits of an intensivist model might be distinct from the utilization of evidence-based practices, suggesting that there might be incremental benefit in using these practices as markers of quality.

From the Division of Trauma and General Surgery (A.B.N., R.V.M., G.J.J.), Harborview Medical Center, Seattle, Washington; the Department of Surgery (A.B.N., R.V.M., G.J.J.), University of Washington, Seattle, Washington; Harborview Injury Prevention and Research Center (A.B.N., R.V.M., G.J.J., D.M., F.P.R.), University of Washington, Seattle, Washington; Center for Injury Research and Policy (E.J.M.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and the Trauma Information and Exchange Program (E.J.M.), American Trauma Society, Upper Marlboro, Maryland.

Submitted for publication August 24, 2004.

Accepted for publication April 28, 2005.

This work was supported by grants R49/CCR002570 and H28/CCH319122 from the Centers for Disease Control and Prevention.

Address for reprints: Avery B. Nathens, MD, PhD, MPH, Harborview Medical Center, Box 359796, 325 9th Ave., Seattle, WA 98104-2499; email: anathens@u.washington.edu.

© 2006 Lippincott Williams & Wilkins, Inc.