Role of Trauma Surgeons at a Regional Trauma Center in South Korea
Article information
Abstract
Purpose
Treatment at a dedicated trauma center significantly reduces the mortality rate after trauma. High-quality trauma care requires well-established systems. Moreover, the presence of an on-site trauma surgeon during resuscitation improves outcomes. Although the trauma system history, including trauma centers in South Korea, is relatively short, it has developed rapidly, and trauma surgeons’ roles have also been established. This study aimed to show clinical performance, particularly in trauma surgery, and the outcomes of a regional trauma center serving as a Level 1 trauma center in South Korea.
Methods
Using the Korean Trauma Data Bank, data collected at Ajou University Hospital Trauma Center between January 2020 and December 2022 was retrospectively analyzed. Patients’ demographic characteristics, mechanisms of injuries, trauma surgery types, and outcomes were evaluated.
Results
There were 9,205 patients admitted with trauma, of whom 1,149 underwent trauma surgery (including laparotomy, thoracotomy, pelvic packing, neck surgery, and peripheral vascular surgery). A total of 1,787 trauma surgeries were performed, and the mean time to surgery for hypotensive patients with hemorrhagic shock from arrival was approximately 50 minutes. Damage control surgery including laparotomy, thoracotomy, and pelvic packing accounted for 12% of cases. It was determined that the mortality rate (excluding death on arrival) was less than 5%, and the length of hospital stay decreased over the study period.
Conclusion
Clinical performance, particularly in trauma surgery, conducted by dedicated trauma surgeons, has led to favorable clinical outcomes at a regional trauma center in South Korea.
Introduction
The establishment of trauma centers enables the provision of high-quality trauma care. High-quality trauma care necessitates a well-established system, including early resuscitation and stabilization strategies. Trauma teams, composed of various medical personnel who promptly initiate resuscitation, require effective team leadership to enhance the trauma care process [1,2]. The immediate involvement of trauma surgeons during resuscitation has been shown to improve outcomes for patients with severe injuries [3]. Trauma surgeons play a crucial role in preventing early traumatic deaths by performing surgery immediately [4]. Furthermore, the specialization of trauma surgeons enhances outcomes in treating trauma intensive care patients [5].
Mortality rates due to trauma and injury accounted for 8.7% of the total deaths in South Korea in 2020, according to data from the Korean Statistical Office [6]. Trauma is considered one of the primary causes of mortality particularly among individuals under 40 years of age. In this context, trauma centers play a vital role in reducing mortality rates following traumatic injuries. In the United States, Level 1 trauma centers have been in operation almost 6 decades. To ensure optimal trauma care delivery, it is crucial to establish specialized trauma centers similar to Level 1 trauma centers in the United States [7]. In 2012, the South Korean government began supporting the installation of regional trauma centers (17 designated by 2022) to establish high-quality trauma care nationwide. Government policy associated with the establishment of the national trauma system initiative, have significantly improved trauma care performance and clinical outcome in South Korea [8]. In 2019, the preventable trauma death rate was recorded as 15.7%, 4.2% lower than that in 2017 [9].
Although the history of the trauma system in South Korea is relatively short, it has developed rapidly, and the role of trauma surgeons has been established. This study aimed to evaluate the clinical performance, particularly in trauma surgery, of dedicated trauma surgeons at a regional trauma center serving as a Level 1 trauma center in South Korea.
Materials and Methods
1. Facilities and human resources
Ajou University Hospital is a tertiary educational medical institution located in Suwon City, South Korea, operating as a regional trauma center, equivalent to a Level 1 trauma center in the United States. The institution was selected by the Korean government as a recipient of the “Regional Trauma Center Installation Support Project” in 2013, and after a preparatory period, it officially opened in 2016, and has been operating at full capacity since then. The institution’s trauma center operates 24/7, is equipped with 2 trauma bays for emergency treatment, has 3 dedicated trauma operating rooms, an interventional radiology suite for trauma, a trauma intensive care unit (with 40 beds), and trauma-specific general wards (60 beds). Considerable effort goes into maintaining the standards and quality of care of a Level 1 trauma center and sustaining an appropriate number of trauma admissions.
A Division of Trauma Surgery operates within the Department of Surgery, and exclusively treats trauma inpatients who present in the Trauma Resuscitation Room in the regional trauma center and the Emergency Department in the regional emergency medical center. The Division of Trauma Surgery operates a dedicated trauma surgery service with an in-hospital duty system. The Division of Trauma Surgery team consists of 16 specialists exclusively dedicated to treating patients with trauma. The specialists received training in the form of a 2-year trauma fellowship program. Among them, there are 12 general surgeons, 2 cardiovascular thoracic surgeons, and 2 emergency medicine specialists who are trauma fellowship board-certified and responsible for the treatment of inpatients including trauma resuscitation, trauma surgery, critical care, and physician-staffed helicopter transfers. There is a day shift and a night shift which begin at 08:00 and 18:00, respectively. A shift is staffed by 3 surgeons, designated as the resuscitation team, from general surgery (GS), cardiothoracovascular surgery (CS), or emergency medicine (EM). On some days, all 3 surgeons may be specialists in GS; on other days, there may be 2 surgeons from GS and 1 CS or EM specialist; and on another day, the team might consist of 1 GS, 1 CS, and 1 EM specialist. The day shift personnel are designated as backup staff for the night shift. If additional staff are required due to the arrival of multiple patients during the day, the night shift personnel, who are on-call for that day, will be called in for support as a priority. In addition, there is an on-call rota consisting of 6 orthopedic specialists dedicated to treating patients with trauma, 1 neurosurgery specialist, and 3 anesthesiology specialists in the rotational duty system.
2. Clinical involvement
Each trauma team comprises physicians including dedicated trauma surgeons, nurses, and allied health personnel. All physicians are trained in advanced trauma life support. During a high-level response to a patient with severe injury, the team is assembled within 15 minutes of the patient’s arrival. During the prehospital phase, the trauma team is contacted directly by emergency medical services (EMS) to relay information categorically about the patient’s medical condition. If the distance is too far to travel by road, the patient is directly transported from the scene to hospital via helicopter. The trauma team conducts gatekeeping and initial resuscitations. Moreover, dedicated trauma surgeons provide definitive care such as surgery, immediate resuscitation (including hemostasis of the abdominal, pelvic, thoracic, cervical, and peripheral vessels), and care in the intensive care unit (ICU). Typically, trauma fellowship board-certified general surgeons performed damage control laparotomies and conventional laparotomies, while board-certified cardiovascular thoracic surgeons carried out damage control thoracotomies and conventional thoracotomies. Additionally, in critical situations, resuscitation procedures, including resuscitative thoracotomy, were performed by board-certified general surgeons, cardiovascular thoracic surgeons, and emergency physicians. Qualified neurosurgeons and orthopedic surgeons participate in the care of patients, and on-call specialists (such as anesthesiologists and radiologists) coordinate patient interventions as defined by the guidelines.
3. Data collection and statistical analysis
Using the Korea Trauma Data Bank dictionary (benchmarked against the National Trauma Data Bank in the United States), our center’s data was analyzed from January 2020 to December 2022. All trauma admissions recorded in the trauma registry were evaluated to perform a comparative analysis of the performance improvement and patient safety program implemented at the trauma center. The differences in performance and outcomes between January 2020 and December 2022 were evaluated using analysis of variance for continuous variables and the chi-square test for categorical variables. The Jonckheere–Terpstra test was used to assess the tendency of the dependent variables to increase or decrease with respect to the change in the independent variables. All statistical analyses were conducted using IBM SPSS software (Version 25; IBM Corp., Armonk, NY, USA). A p < 0.05 was considered statistically significant.
Results
1. Characteristics of patients with trauma
During the 3-year study period between January 2020 and December 2022, there were 9,205 patients admitted with trauma. The number of patients with severe trauma admitted to the trauma center and emergency medical center increased annually. Approximately 74% of patients with trauma were admitted to the regional trauma center. The number of patients who directly visited the trauma center increased significantly. The mean age of patients was the highest in 2022, and blunt trauma was the most predominant form of trauma in 2022. The number of patients with an Injury Severity Score ≥ 15, and those admitted to ICU increased over time; however, of the number of registered trauma patients, the proportion of patients decreased during the study period (Table 1).
Changes in Characteristics of Patients with Trauma Admitted to Ajou University Hospital Trauma Center
2. Surgical performance of dedicated trauma surgeons
The number of surgeries performed by dedicated trauma surgeons and orthopedic surgeons showed an increasing trend (Figure 1). Over 3 years, dedicated trauma surgeons performed 1,787 surgeries for 1,149 patients under general anesthesia. The average time from the trauma bay to the operating room for hypotensive patients presenting with hemorrhagic shock significantly reduced in this period (p = 0.023). Damage control surgery which included gauze packing, bowel or duct resection without anastomosis, and temporary closure, was performed for hemodynamically unstable patients. Second- and 3rd-look surgeries were performed using the laparotomy and thoracotomy procedures. Over the 3 years 214 thoracotomies were performed, of which, 41 were cardiac surgeries. Laparotomies accounted for the largest proportion of surgeries performed by dedicated trauma surgeons. Damage control laparotomies and thoracotomies accounted for about 10% of procedures, and the number of damage control thoracotomies increased significantly during the study period (p = 0.019; Table 2).
Number of surgeries performed by dedicated trauma surgeons at Ajou University Hospital Trauma Center from 2020 to 2022, according to the surgical department. The number of surgeries performed by dedicated trauma surgeons and orthopedic surgeons showed an increasing trend over time.
* Within the Department of Trauma Surgery, the number of surgical procedures significantly increased between 2020 and 2022 (p = 0.001).
† Within the Department of Orthopedic Surgery, the number of surgical procedures significantly increased between 2020 and 2022 (p = 0.048).
Trauma Surgery Under General Anesthesia in The Operating Room at Ajou University Hospital Trauma Center
Dedicated trauma surgeons performed laparotomies using various surgical procedures for different organs. Among the 810 patients who underwent a laparotomy, a total of 892 surgical procedures were performed (excluding those related to follow-up operations). Gastrointestinal surgery accounted for the largest proportion of surgeries, followed by surgery for the liver, pancreas, duodenum and bile duct, spleen, major vessels, and urinary tract (Table 3). For the abdominal and pelvic regions, the most frequent surgical skills were bowel or mesenteric sutures and bowel resections. Additionally, resuscitation procedures, such as resuscitative thoracotomies, resuscitative endovascular balloon occlusions, and preperitoneal pelvic packing, were performed by dedicated trauma surgeons in the trauma bay and operating room (Table 4).
Abdominal and Pelvic Surgical Procedures in The Operating Room at Ajou University Hospital Trauma Center
Procedures for Resuscitation in The Trauma Bays and Operating Rooms at Ajou University Hospital Trauma Center
3. Clinical outcomes
Among all patients included in this study, the mortality rate, excluding deaths on arrival, remained < 5%, with no significant differences observed over the 3-year study period. However, significant differences were observed in the length of hospital stay (p = 0.005; Table 5).
Clinical Outcomes at the Ajou University Hospital Trauma Center
Discussion
The performance of dedicated trauma surgeons at Ajou University Hospital Trauma Center reflects a commendable commitment to providing prompt and efficient trauma care. Over the study period, there was a notable increase in the number of surgeries performed by dedicated trauma surgeons, underscoring the center’s proactive approach to managing traumatic injuries. Furthermore, the implementation of damage control surgery including laparotomy and thoracotomy techniques, highlights the center’s adaptability to handle hemodynamically unstable patients effectively. Notably, the surgical procedures employed ranged from gastrointestinal surgeries to major vessel repairs, highlighting the breadth of expertise available at the trauma center.
Importantly, the clinical outcomes observed at Ajou University Hospital Trauma Center are promising, with mortality rates consistently maintained below 5% over the study period. Moreover, there were significant reductions in the length of hospital stay, indicative of enhanced patient recovery and streamlined healthcare delivery. The improvements in clinical outcomes determined by this retrospective study are likely the result of enhancement in the quality of the trauma care system.
In this trauma center over the 3-year study period, there were 1,787 trauma surgeries performed by dedicated trauma surgeons on 1,149 patients with trauma. A single center study of a regional trauma center conducted in South Korea reported that trauma surgical volume (as a metric of delivering surgical care by trauma team dedicated surgeons) was very low [10]. However, the number of trauma surgeries performed by dedicated trauma surgeons is sufficient in some regional trauma centers, including the center in this current study.
Trauma surgeries in this study were performed on the abdomen, pelvis, thorax, neck, and peripheral vessels for hemostasis as well as elimination of contamination. Laparotomies involved various surgical procedures for different organs. These skills include most of the trauma care skills required by general surgeons [11]. Unlike specialized modern general surgery, dedicated trauma surgeons repair all organs in the abdominal cavity. In addition, dedicated trauma surgeons perform resuscitation in the trauma bay or operating room for unstable patients.
One study retrospectively analyzed emergent laparotomy data (N = 8,588) from the American College of Surgeons Trauma Quality Improvement Program stratified trauma centers in Arizona based on the number of laparotomies in 2017 [12]. A high-volume center, defined as one that performed more than 25 laparotomies per year had higher survival rates than medium and low volume centers [12]. There were 98 patients who underwent trauma laparotomies during a 2-year period (2019–2020) that were performed by a dedicated trauma team at Copenhagen University Hospital [13]. At our trauma center, 810 patients underwent laparotomies (2020–2022) which were performed by dedicated trauma surgeons, and the study population predominantly comprised patients with blunt trauma, which was a higher number than that reported in other studies.
The mortality rate, except deaths on arrival, in this center was maintained below 5%. In a comparative study in 2006, Mackenzie et al reported that the national mortality at trauma centers in the US was low (7.6%), as compared with treatment at non-trauma centers (9.5%) [7]. In a recent systematic review and meta-analysis of peer-reviewed studies (N = 52) published in English between 2000 and 2020 on the effectiveness of trauma care systems at reducing mortality, the in-hospital mortality rate for patients treated at a less established trauma center was 7.1%, and for those treated in an experienced more established trauma system the in-hospital mortality rate was 6.73% [14]. The mortality in 2022 was 4.5% in our center (lower than that in other centers). An established trauma system with an experienced trauma team in a regional trauma center, as well as aggressive surgery for hemostasis by dedicated trauma surgeons, may be associated with the improvement in in-hospital mortality rates.
Trauma systems have been previously studied and have evolved in many countries, e.g., across Europe, and the United States [15,16]. In 1976, the American College of Surgeons established a regional trauma system equipped with the resources necessary for immediate and definitive care of patients with trauma. Moreover, European committees created systems that included prehospital care, in-hospital care, and standardized treatment protocols. At our trauma center, dedicated trauma surgeons are involved in treatment from the prehospital phase and actively implement resuscitation through gatekeeping. Dedicated trauma surgeons provide prehospital guidance for EMS and resuscitation for approximately 3,000 patients admitted to trauma centers annually. During the prehospital phase, dedicated trauma surgeons are directly contacted by EMS to provide direct medical information about the patient. If the distance is too far to travel by road, patients may be transported directly by helicopter. In addition, trauma surgeons perform surgery and provide leadership during the care of patients with polytrauma in the ICU, and in the general wards, and conduct follow-ups in the outpatient clinic.
Rapid trauma response is important to provide effective treatment for severely injured patients. It was reported in a systematic review of trauma patient data in in 2020 (N = 64,337) and meta-analysis (n = 7,490) of in-house versus oncall trauma surgeon coverage by de la Mar et al [17] that the policy of having a 24/7 in-house trauma surgeon was statistically significantly associated with reduced mortality rates in Level 1 trauma centers. As far back as 2009, McKenny et al [18] reported that the mortality rates for patients with severe injuries bear a significant correlation with the surgeon’s experience at the trauma center. In addition, studies [19,20] have showed that treatment at an appropriate trauma center and the actions of the trauma team leader exerted a positive influence on patients with severe traumatic brain injury.
This study has some limitations. Firstly, bias may have existed due to the retrospective study design. Secondly, this study was conducted at a single center for patients with trauma. Despite these limitations, we believe that this study can be objectively evaluated. Trauma team surgeons in this study worked using the roles set out by experienced trauma surgeons in established trauma centers in the US, and robust performance improvement initiatives were in place. The data in this study was quantified, and the clinical performance and outcomes of one of the most active trauma centers in South Korea was analyzed.
Conclusion
The comprehensive approach adopted by Ajou University Hospital Trauma Center, characterized by skilled human resources, robust performance improvement initiatives, and adherence to international standards, has resulted in favorable clinical outcomes which are comparable to those observed in advanced trauma care settings. This study reaffirms the pivotal role of dedicated trauma centers in optimizing trauma patient care and underscores the importance of continual quality assessment and improvement in trauma management.
Acknowledgment
The authors would like to express their sincere gratitude to the trauma center data registrars, and the coordinators of the performance improvement, and patient safety team for their invaluable assistance in data collection and organization during the course of this study.
Notes
Author Contributions
Conceptualization: SD and JK. Data curation: SD, HI, JH, and JK. Formal analysis: SD, HI, JH, and JK. Investigation: SD, HI, JH, and JK. Methodology: SD and JK. Supervision: JK. Validation: SD and JK. Visualization: SD, HI, JH, and JK. Writing - original draft: SD, HI, and JK. Writing - review & editing: SD, HI, JH, and JK. All authors have read and agreed to the published version of the manuscript.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
This research received no external funding.
Ethical Statement
This study was approved by Institutional Review Board of Ajou University (no.: AJOUIRB-DB-2024-106).
Data Availability
The data and materials that support the study findings are available upon reasonable request from the corresponding author.