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Building a Balanced Trauma Team – Determining the Right Mix of Nonphysician Staff

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The importance of trauma centers cannot be overstated. They are the first line of care for the most serious injuries that patients suffer, from broken bones to head trauma to gunshot wounds. The heroic actions of emergency physicians and their staff can be the difference between life and death. It’s surprising, then, that the American College of Surgeons (ACS), the association charged with setting standards for surgical care, offers little guidance on trauma center staffing – particularly for the nonphysician staff who extend and support physicians.

In a recent study, ECG Senior Manager Jason Lee and Senior Consultant Dwight Asuncion examined nonphysician staffing at 14 Level II trauma centers in an effort to offer guidance on appropriate staffing and personnel ratios. They published their results last month in an article for H&HN. Here, they discuss their findings and describe the challenges that trauma centers face in determining the most effective way to use nonphysician staff to bolster their services.

When we think about trauma centers, most of us probably envision physicians conducting emergency surgeries on patients. But physicians need a strong supporting staff to be truly effective. What are some of the key roles that nonphysicians play in a trauma center?

Dwight: The most visible are the midlevel providers – RNs, nurse practitioners, physician assistants. They play an important role since they’re the first line of defense, if you will, when patients come in. They assess the acuity of the patients and then page the physicians to come in, if the case calls for it.

Jason: On the administrative side, there’s the program manager, who typically has responsibility for developing the schedules for the physicians and the midlevel providers. Reporting to the program manager is the injury prevention coordinator. That’s an external-facing role that tries to reduce the number of traumas in the community through advocacy, education, and enhanced safety in the workplace. The process improvement coordinator is responsible for improving the efficiency of the actual care of trauma patients. Finally there are the registrars, who are responsible for documenting all of the trauma activity and reporting out to ACS and Medicare.

Clearly, trauma care is a collaborative effort. But as you explain in your article, there isn’t much consistency when it comes to trauma center staffing.

Dwight: There is some guidance from ACS for physicians, but for midlevel providers and administrative staff, there’s little to none.

Why is that guidance necessary?

Jason: In this day and age, with so much emphasis on managing the overall cost of care, it’s important that organizations have data to ensure they’re properly serving their population. A lot of organizations want to put together great teams and provide the appropriate level of care at a good value, but given the dearth of information that Dwight mentioned, they’re struggling to understand the best way to do that. We felt like this article would be a good opportunity to share some of what we’ve learned, given our client experience and the research that we were able to complete.

Are there financial advantages to having nonphysicians on the team, or do they represent an added expense?

Jason: The midlevel providers offer an advantage because they are extending the physicians. They are typically the first responders to the patients and determine whether a higher level of care is required. The nonproviders are not extending the physicians, but in many ways they can improve efficiency. The process improvement coordinator evaluates the response time, the level of response, and the teams that are in place to respond to patients. The injury prevention coordinator is not an efficiency-related position, but that role is important when it comes to broader population health and reducing the overall cost of care. For example, one organization we spoke with treated a huge number of injuries from a nearby trampoline park, because their safety precautions weren’t sufficient. Injury prevention coordinators work with the community to implement policies or regulations around safe practices.

Given the importance of trauma centers, and the key roles that nonphysicians play, why is there so little guidance from ACS on what constitutes appropriate staffing?

Dwight: I think part of it is just lack of manpower to do the benchmarking analysis that we did, conduct qualitative interviews with different trauma program managers, and perform the quantitative assessment, in which we accounted for both acuity and volume.

Jason: Another issue is that there are only several hundred trauma programs across the country, and they serve an array of different geographies. Because of that, there’s not enough political will to go through the effort that Dwight described.

At the same time, it’s only in the last 10 years or so that there’s been an explosion of organizations actively trying to achieve trauma designations. Trauma programs can bring prestige to a health system in the eyes of the public and also serve as a source of patients in need of an array of procedures and services. Many of these organizations have provided trauma services in the past, but in terms of staffing ratios, they would sort of just wing it, using anecdotal evidence and whatever networking information they might be able to get. So nonphysician staffing has not typically been a point of emphasis for ACS, but with so many organizations seeking clear designations, those questions have come up.

Now that you’re providing answers to those questions, what should trauma center leaders do with this new information?

Jason: The program managers and coordinators will be best served by using this information to do a peer comparison and to have fact-based discussions with leadership around whether the trauma program can be funded at an appropriate level. They ought to be reviewing their teams to ensure they are providing a trauma service in an effective way. It really is about putting the best data in the hands of the people who are leading these teams so they can be honest with themselves about whether their program is appropriately and efficiently staffed for the service they need to provide.

Jason Lee has spent more than a decade partnering with healthcare providers, and his current practice focuses on developing hospital/physician financial relationships and assessing physician productivity. Dwight Asuncion works closely with physicians, executives, and front-line staff to implement strategy and improve hospital operations. Read their detailed findings on effective nonphysician staffing ratios in Trauma Centers Need Nonphysicians in the Mix, which appears in the April edition of H&HN.