We assessed whether a trauma service model with an emphasis on continuity of care by using “shift work” will improve trauma outcomes and cost. This was a case-control cohort study that took place at a university-affiliated Level I trauma center. All patients (n = 4283) evaluated for traumatic injuries between May 1, 2002 and April 30, 2004 were included. During Period I (May 1, 2002 to April 30, 2003), a rotating off-service team provided initial management between 5:00 PM and 7:00 AM. The “day team” provided all other care and was responsible for continuity of care. In Period II (May 1, 2003 to April 30, 2004), a dedicated trauma service consisting of two resident teams evaluated all injured patients. Variables included hospital and intensive care unit length of stay (LOS), mechanical ventilation requirements, hospital mortality, and hospital care costs. Demographics and injury mechanism for both periods were similar, but Injury Severity Score (ISS) in Period II was greater (ISS, 8.2% vs 7.2%, P < 0.0001; ISS > 15, 18.5% vs 15.4%). In the more severely injured (ISS > 15), patients in Period II had shorter hospital LOS (8.6 vs 9.7 days, P = 0.98), a shorter ICU LOS (5.5 vs 7.7 days, P = 0.039), shorter mechanical ventilator requirements (5.5 vs 7.7 days, P = 0.32), improved hospital mortality rate (19.9% vs 26.8%, P = 0.029), and decreased hospital costs ($19,146 vs $21,274, P = 0.36). On multivariate analysis, factors affecting mortality and LOS included age, initial vital signs, injury type, and ISS. Overall, the two trauma service models resulted in similar outcomes. Although multivariate analysis revealed that treatment period did not affect mortality, our study revealed improved patient survival and reduction in LOS and cost for the severely injured in Period II.
Variability of serum phenytoin levels in critically ill head injured patients in intensive care unit
