Merging of two level-1 trauma centers in Amsterdam: premerger demand in integrated acute trauma care

This study examined the current premerger demand for level-1 trauma care in integrated acute care involving two level-1 trauma centers in the Amsterdam region. During the study period, 8277 patients required trauma care, of which 60.4% at location A and 39.6% at location B. Overall, 462 patients were considered severely injured. Due to the expert care delivered in level-1 trauma centers, it is crucial to ensure the appropriate availability of capacity of staff and resources. Based on varying volume effects after merger described in the literature [11,12,13,14], the extrapolation of an expectation model to the current situation is challenging. Pragmatically, the demand for trauma care in the post-merger setting considered as a sum of care demand of both centers resulted in a 167.4% increase in trauma patients and a 151.1% increase in severely injured patients for location B. Moreover, on 96 occasions annually, two or more patients within the same hour would require advanced trauma resuscitation by a specialized team or emergency surgery.

To manage increased patient input on a tactical and operational level, the literature emphasizes the importance of optimizing throughput and output components of acute care flow [19]. Early assessment of potentially required adaptations in the post-merger center seems preferable. Mentzoni et al. detected an increased input of 40.9% and a corresponding rise in LOS of 20.9% the first year after their Norwegian catchment area was reconfigured by 44%. This increased input expanded further during peak hours [20]. To prevent crowding and a prolonged LOS in ED, several capacities-enhancing strategies include optimizing triage, increasing the number of staffed beds, and installing additional wards as temporary in-patient dispositions [3, 19,20,21,22].

Generally, reducing LOS in academic hospitals is challenging due to the complexity of care and treatments [23, 24]. Together with the admission rate, it forms a substantially important factor influencing hospital-level flow through a unit [25], and is highly dependent on the urgency of admission and admission season [26, 27]. This current study found a median LOS in ED of 2:44 h for location A and 2:33 h for location B, which is similar to the national ED LOS in our inclusive trauma system [28] and mirrors previous findings from a different Dutch level-1 trauma center [29]. For patients requiring advanced care at the trauma resuscitation room, mean times of 3:55 h (location A) and 2:54 h (location B) were found. This duration included the time spent in a regular ED bed after their trauma resuscitation was completed when no further care at the trauma resuscitation room was required. Furthermore, It was shown by McCarthy et al. that decreasing the number of patients waiting to ‘board’ to their in-patient disposition has the greatest benefits for flow efficiency and overcoming ED crowding [21]. Therefore, considering the two merging academic level-1 trauma centers, one strategy to reduce LOS could be increasing the number of staffed beds in the clinical trauma wards and temporary disposition wards [30]. This would contribute to ED output by decreasing ED boarding time and aid the overall increase in patient input over all three shifts ranging from 150.0 and 160.9%, as depicted in this study’s results.

In addition, due to the emergent character of trauma care, a specialized team can be ‘fixed and saturated’ with resuscitating one severely injured patient. This study found that the arrival of severely injured patients in the ED would mainly occur during the evening and night shifts. The overlap of two patients requiring advanced trauma resuscitation in ED within one hour would be most common during evening shifts. Therefore, attention to providing adequate staffing and resources for initial trauma resuscitation in ED during these shifts could contribute to optimizing patient throughput. To achieve this in the post-merger setting, installment of 24–7 in-house trauma surgeon presence and stand-by coverage by an additional trauma surgeon can aid in warranting continuity of care.

Moreover, besides, after severe trauma, a patient often requires further resuscitative management, such as damage control surgery or primary fracture care in an emergency setting and further definitive care at the ICU. Consequently, OR and ICU admission availability is essential to warrant level-1 trauma care delivery. In total, the amount of ICU admissions accounted for 17.7% of all trauma-related admissions. Adding up both centers would result in a 115.6% increase in trauma-related ICU admissions, mainly during the evening and night shifts. Therefore, to comply with the current standards from the Dutch Trauma Society (NVT) for a level-1 trauma center to always have one ICU bed available at all times to admit a severely injured patient [3], expanding the minimum availability to two ICU beds might be required to cope with the potential increase in the post-merger setting. Capacity-enhancing strategies include facilitation for ICU patients who require observation due to, for example, costal fractures to be monitored at the Post Anesthesia Care Unit (PACU). Also, to preserve the continuity of the OR schedule, the intensivist will aim to replace the anesthesiologist’s role during trauma resuscitation activations in ED. This way, the (emergency) OR will be minimally impacted regarding staffing availability.

Concerning staff expansion, it is advantageous that the attending intensivists already work in a shared staffing pool between the two centers. However, high demand exists for (specialized) nurses in the trauma resuscitation room, OR, ICU, and clinical ward [31]. Therefore, concerning capacity expansion, the most significant bottleneck will likely be facilitating adequate nursing staffing. Overall, investment in staffed beds in the clinical trauma ward benefits a two-tiered strategy, as it supports both output flow in ED and ICU [32]. Naturally, optimal flow towards the clinical trauma ward comes hand in hand with ensuring adequate availability by preventing a stagnating output flow in the clinical department. The majority of patients in the clinical ward were discharged to their own living environment (74.7%), with additional home care if necessary, whereas 9.6% of patients were discharged to a nursing home and 4.6% to a rehabilitation clinic. The corresponding arrangements and transfer to continue the required care at home, nursing home, or rehabilitation clinic usually only occur during weekdays. In the case of admitted clinical patients for whom hospital care is no longer necessary, delays concerning organizational and logistical aspects of discharge disposition cause unnecessary hospital bed occupancy. While the number of nursing- or rehab capacity would not change in the catchment area due to the merger, arranging the patients to be dispositioned to these beds might be more challenging. The literature showed that multidisciplinary attention to discharge planning has effectively reduced unnecessary LOS [33]. An additional improvement to overcome this could include optimizing discharge possibilities on a 7-day per week basis and continuing the required care in the (nursing-)home or rehabilitation setting.

Altogether, the in-hospital care flow forms a connected entity dependent on individual departments’ flow and collective collaboration. Besides the anticipated volume effects caused directly by the merger, due to the integral character of trauma care, regional restructuring of patient flow seems necessary to meet the novel > 90% standards for severely injured patients in the post-merger setting [7]. Several studies showed undertriage rates between 21.6 and 34.6% among various Dutch trauma regions [34,35,36,37]. To aim for severely injured patients to be directly transported to the level-1 trauma center, triage should be enhanced for the ‘potentially severely injured patients’ to be evaluated in the level-1 trauma center and thus reduce undertriage. A clear two-way interaction with level-2 trauma centers should be established to mitigate this increased patient input. That way, patients who, after evaluation in the level-1 trauma center, do not sustain severe injury and otherwise do not benefit from level-1 trauma care can be transferred safely to a surrounding level-2 trauma center when necessary.

In this study, the retrospective inclusion of all trauma patients presented through the ED with acute traumatic injury might have caused to some extent, selection bias. Patients admitted via other (e.g., elective) routes might have been missed. However, focusing on the patients admitted via ED provided a thorough insight into the patient’s integrated care flow. Patient flow is rather erratic and non-linear [38]. In addition, the analysis of the transport time difference in the post-merger setting only included admitted patients from location A from whom the scene location was available. The present study was conducted assuming that a merger would directly translate into a sum of the demand for care from both trauma centers. Despite it being uncertain whether a merger results in this input, in the literature, effects on volume after a merger are controversial [14] and do not readily generalize to the trauma system setting. Nevertheless, generally, in acute care, one large unit is more efficient than two small ones [32], which is in line with one of the general strategies of hospital mergers to reduce duplication of services [10, 12]. Therefore, the sum of capacity adhered in this current study might function as a maximum baseline for the required capacity.

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