The association between seniority of Accident and Emergency doctor and outcome following trauma
Introduction
Deficiencies in the management of patients with trauma in the UK have been well publicised and highlighted1, 2, 3. Retrospective review of 1000 deaths after trauma by the Royal College of Surgeons of England concluded that some deaths were unnecessary and that many were associated with delivery of emergency care by inexperienced doctors[1]. These conclusions were based upon subjective retrospective analysis of case notes, objective evidence based upon prospective data regarding the importance of experience of the resuscitating team is somewhat lacking.
The focus regarding the initial reception and resuscitation of the injured patient has naturally fallen upon the senior doctor (or resuscitating `team leader') in the Accident and Emergency (A&E) department. As a result, some hospitals in the UK have dramatically altered their A&E staffing levels and work patterns in order to increase the immediate availability of experienced doctors to manage seriously injured patents[4]. Unfortunately, attempting to elucidate the effect of the presence of senior staff within such hospitals is difficult5, 6. Comparing patients' outcomes with those in other hospitals yields information about the effectiveness of different systems of care within two different hospitals, which may be influenced by numerous other factors apart from differences in seniority of accident and emergency staff5, 6. In order to try to investigate the way in which the level of seniority of accident and emergency (A&E) doctor influences outcome after trauma, different cohorts of patients treated within the same hospitals need to be compared.
Section snippets
Patients and methods
The trauma care delivered in four Scottish hospitals (Edinburgh Royal Infirmary, Aberdeen Royal Infirmary, Glasgow Western Infirmary and Glasgow Royal Infirmary) was studied prospectively by the Scottish Trauma Audit Group between February 1992 and December 1996. Criteria for inclusion in the study were those used previously by the Major Trauma Outcome Study, which specifically exclude children aged less than 13 years and elderly patients with isolated (osteoporotic) neck of femur fractures or
Results
The 1208 patients treated by an A&E consultant had a significantly better outcome than the 9195 patients treated by junior staff (Fig. 1). Although significantly (p<0.01) more patients seen by a consultant presented to A&E during `normal' working hours (Monday–Friday, 9 a.m.–5 p.m.), analysis of outcome according to time of presentation revealed that the difference in outcome associated with consultant presence was more exaggerated outside than during `normal working hours' (Fig. 2). Further
Discussion
The organisation of trauma services in the UK remains controversial5, 6, 11, 12, 13, 14. There have been calls for every hospital which manages seriously injured patients to install trauma teams comprising experienced doctors15, 16, 17. Improved outcome might be intuitively anticipated when patients with potentially life threatening emergencies are managed by trained and experienced doctors, but proving this is not easy. A randomised controlled trial of treatment by A&E consultants against
Acknowledgements
We thank the Scottish Trauma Audit Group for help with this study. J.W. was funded by a University of Edinburgh Faculty of Medicine Research Fellowship.
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