Title:
In-house direct supervision by an attending is associated with differences in the care of patients with a blunt splenic injury.

Abstract:
There continues to be controversy over the added value of direct supervision of residents, particularly its effect on patient outcomes. The purpose of this study was to compare direct and indirect resident supervision for the management of blunt spleen injuries and to evaluate differences in patient care.
All patients with blunt splenic injury admitted off hours over a 6.5-year period to a regional level I trauma center were analyzed. Data analyzed included patient demographics, injury characteristics, hospital course, and treatment modality. Direct supervision was defined as the presence of a surgical attending on call in the hospital. Indirect supervision was defined as the surgical attending taking the call from home. Primary analysis consisted of a comparison of outcomes and compliance with a protocol for nonoperative management (NOM) between these groups.
There were 506 total cases, of which 274 (54%) were directly supervised, 157 (31%) had indirect supervision, and 75 (15%) presented when a fellow was the most senior person in house. The mean injury severity score was 21, patients averaged 34 years of age. The splenic salvage rate was 89.7% and the mortality rate was 8.5%. The primary comparison revealed a significantly higher percentage of patients going to operation with direct supervision. Direct supervision was associated with significantly greater protocol compliance for NOM (82% vs 95%; P < .001). Indirect supervision was associated with a greater use of intensive care unit (ICU) resources and protocol noncompliance with the use of splenic artery embolization. The overall success of NOM was 98.6%. Failure of NOM was associated with lack of protocol compliance. Failure of NOM was 9.6% in patients with protocol deviation and 0.3% with protocol adherence. There were no differences in mortality or splenectomy rates between the groups.
This study shows that there were significant differences in the management of blunt splenic injury depending on the type of supervision. Indirect supervision was associated with less compliance with a management protocol, fewer patients undergoing initial operation, more ICU use, increased hospital charges, and a greater use of splenic artery embolization without indication. These results emphasize the value of direct supervision in the management of a select group of trauma patients.