High-Quality Care at Lower Costs
It truly is excellent teamwork, across nearly all of the medical center's domains ... that has allowed us to achieve these population-based results that are highly illustrative of how D-H delivers value: high-quality care at lower costs."
Recently a young man came to the Emergency Department (ED) at Dartmouth-Hitchcock Medical Center (DHMC) at 3:30 AM with lower abdominal pain and vomiting. He'd been snowmobiling at midnight, hit a tree and struck his abdomen on the handlebar.
Right after the accident, he didn't exhibit symptoms, but then began to develop increasing abdominal pain. The ED team performed his initial evaluation, treatment, resuscitation and bedside ultrasound. An emergent CT scan of his abdomen was performed, showing a perforated intestine and pancreatic injury—a potentially fatal condition.
The Trauma and Acute Care Surgery team was consulted, saw him immediately in the emergency room, collaborated with the ED team and took him to the operating room for surgical repair.
The patient went on to make a full recovery, and is now doing well.
Teamwork Drives Excellence
Life and death scenarios like this play out every day in hospitals around the country. But achieving this kind of outcome, and doing it consistently, is anything but commonplace. It requires high-functioning, multi-disciplinary care teams and a structure in place that enables those teams to work together seamlessly to bring optimal care to patients.
Based on these attributes, Dartmouth-Hitchcock's Trauma and Acute Care Surgery team over the past three years has been ranked nationally by the Trauma Quality Improvement Program (TQIP) as one of the top centers in quality and efficiency indicators such as mortality, length of stay and resource utilization.
"When you consider that the severity of illness in trauma patients has increased, it makes our results all the more impressive,"says Richard Freeman, Jr., MD, chair of the Department of Surgery at Dartmouth-Hitchcock.
"It truly is excellent teamwork, across nearly all of the medical center's domains—from the advanced response teams to the ED, to the OR and blood bank, to lab services, the ICU and many other care units and supportive services—that has allowed us to achieve these population-based results that are highly illustrative of how D-H delivers value: high-quality care at lower costs."
Redefining Trauma Care
In the last decade, trends such as the development of laparoscopic surgery, the shift in medicine to ambulatory practice and the increasing prevalence of trauma cases (such as road traffic injuries) as a global health burden have led to profound changes in trauma care.
"Similar to the creation of the hospitalist role, we've been evolving to more of an acute care surgery model—where surgeons who specialize in all surgical emergencies are readily available in a 'trauma center'—in an effort to improve care for complex, high-acuity surgical patients,"explains Rajan Gupta, MD, chief of Trauma and Acute Care Surgery at D-H. "We know from national studies that trauma patients, especially those who are severely injured or ill, have better outcomes in these settings."
For D-H, which is verified by the American College of Surgeons as a Level One Trauma Center, the evolution to this model began about three years ago when Gupta met with D-H's Clinical Workforce Committee. "We got approval to, over the course of three years, add three surgeons to our group so that we could provide 24-7, in-house acute care surgery coverage,"he says.
About 180 Level One and Level Two trauma centers across the country submit their data to TQIP, and as mentioned earlier D-H's efforts have led to some impressive results.
"When comparing ourselves to all of the great trauma centers out there, we're in the top 10 to 20 percent in regards to major complications and death in four out of the eight major categories that TQIP looks at,"says Gupta. "At the same time, we've reduced our hospital and ICU (Intensive Care Unit) lengths of stay by at least a half day each and produced a positive financial operating margin of 3 percent for the trauma center."
Preparing for Tomorrow's Patients
The educational impact of D-H's success in this arena is not only helping to enhance interest and support of its top-notch surgical residency programs, it is laying the groundwork for improving the region's trauma care in the future.
"In trauma centers like D-H, the response is incredibly prompt and well orchestrated between the ED, surgery, sub-specialists areas and other services—but that's not the model of most of the country or our region,"explains ED physician Kevin Curtis, MD, MS, who directs D-H's Emergency Medicine Residency Program, the only such training program in New Hampshire or Vermont.
In most rural community hospitals, the initial management of trauma patients who will go on to need acute care surgery is done by emergency physicians. "As many as 50 percent of our residents may stay in the region,"he says. "Making sure that they spend time on our Trauma and Acute Care Surgery team ensures that they receive the training, education and competency they need to be able to handle the early evaluation and resuscitation of trauma patients effectively."
One young physician in training, who's seen the evolution of the trauma and acute care surgery model over several years at D-H and can speak to its positive impact, is senior surgical resident Jessie Wallaert, MD.
"It used to be that the general surgeon 'attendings' split all of the call, so you'd have any number of people dealing with any number of things that they might not see on a regular basis,"she says. "Now that we have one dedicated service, the continuity of care has definitely improved. We're also able to take more referrals because we have overnight coverage. All around, it's better for the patients."
"And from a resident education perspective, I think we get a lot more out of the new model,"says Wallaert. "Having attendings in-house has been invaluable. They're much more likely to come and see a patient and say to us, 'I agree or disagree with your assessment,' and 'let's talk about what your thought process was.' We get those opportunities for on-the-spot learning that just weren't there before."