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From private to academic call: Implementation of a dedicated orthopaedic trauma room on hip-fracture timeliness and efficiency
, Ibrahim Rababaa,b, Zachary Coxa,b, Keelan Spencerd, Alan Afsaria,b, Adam Fahsa,b, Benjamin Besta,b
⁎Corresponding author: Usher Khan
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Evaluate whether implementation of an academic trauma team and a dedicated orthopaedic trauma room (DOTR) reduces surgical delay and improves efficiency in hip fracture management at a Level III trauma center.
Design: Retrospective comparative cohort study.
Setting: Single Level III community trauma center.
Patient selection criteria: Adults undergoing operative repair of hip or femoral neck fractures in 2022 (private group, PG) or 2023 (academic group, AG). Exclusions include door-to-operating-room time >10 days, dialysis, active infection, revision surgery, preoperative ICU admission.
Outcome measures and comparisons: Primary outcome measured was door-to-operating-room time (DTOR); secondary outcomes included proportion with DTOR >36 h, DOTR start-time utilization, hospital length of stay (LOS), age, body mass index (BMI), and Charlson Comorbidity Index (CCI) score.
A total of 433 patients met criteria (PG = 200, AG = 233). Groups were similar in age, BMI, and CCI (all p > 0.05). Median DTOR fell from 20.5 h to 16.5 h after DOTR implementation (p < 0.001). The amount of patients waiting greater than 36 h decreased from 21 % to 6.0 % (p < 0.001). DOTR start-time utilization rose from 22.5 % to 35.0 % (p = 0.005). LOS decreased from 137 h to 131 h but was not significant (p = 0.184).
A multidisciplinary academic trauma service with a morning DOTR was associated with shorter time to surgery and higher OR start-time utilization for hip fracture patients, with a favorable trend toward shorter hospitalization. Adopting a dedicated trauma room and structured communication can enhance efficiency and patient care in community trauma centers.
III.
Keywords
Hip fracture
Orthopaedic trauma room
Door-to-OR-Time
Length of stay
Efficiency
1 Introduction
Hip fractures impose a substantial and growing burden on the U.S. healthcare system. Each year, approximately 325,000 such injuries occur nationwide, and recent inpatient data show a mean hospital stay of 5.3 days, an average cost of $17,764 per admission, and aggregate 2018 expenditures approaching $5.8 billion.1 Timely surgical intervention is critical: the American Academy of Orthopaedic Surgeons (AAOS) recommends operative fixation within 24-48 h of admission, a window consistently linked to lower 1-year mortality and reduced peri-operative complications, including pressure ulcers, pneumonia, and venous thromboembolism.2
To meet these time-sensitive benchmarks, many hospitals have instituted dedicated orthopaedic trauma rooms (DOTRs). Multiple studies demonstrate that DOTRs shorten door-to-operating-room intervals, decrease the overall length of stay, and lower perioperative morbidity while reducing the need for surgeries outside regular hours.3–6 Streamlined scheduling and resource allocation in a DOTR can further yield measurable institutional cost savings.7
Nevertheless, evidence remains limited regarding DOTR performance in community trauma centers, where staffing models and resources differ from tertiary academic hospitals. Leveraging a complete transition from private practice to academic orthopaedic coverage at our Level III trauma center, the present study assesses whether coupling an academic trauma team with a morning DOTR improves surgical timeliness and operational efficiency in hip fracture care.
2 Methods
A retrospective cohort study was conducted at a single Level III community trauma center, evaluating operative hip and femoral neck fractures treated from January 1, 2022 through December 31, 2023. A dedicated orthopaedic trauma start time of 07:30 h was maintained seven days per week for the entire study interval. An abrupt change in staffing on January 1, 2023 created two distinct care models for comparison.
2.1 Private-group period (PG; 2022)
During calendar year 2022, fracture care was provided by a private practice composed of three elective adult reconstruction surgeons, one elective sports medicine surgeon, and four practice-based physician assistants (PAs). This team furnished night and weekend call coverage exclusively, and no resident involvement was present.
2.2 Academic-group period (AG; 2023)
Beginning January 1, 2023, call coverage was assumed by an academic orthopaedic service consisting of three fellowship-trained orthopaedic traumatologists, two orthopaedic surgery residents, and two hospital-employed PAs. Department leadership transitioned concurrently from the private practice chief to one of the academic traumatologists, who also served as residency program director. To streamline perioperative logistics, an encrypted group-messaging thread connecting on-call attendings, residents, and orthopaedic PAs was instituted, enabling real-time assignment of surgical cases, coordination of pre-operative clearance, and confirmation of dedicated orthopaedic trauma room (DOTR) utilization.
2.3 Eligibility criteria
Inclusion required operative fixation within 10 days of emergency department arrival. Exclusion criteria were renal replacement therapy, active systemic infection, revision surgery, or requirement for intensive-care admission before the index operation.
2.4 Cohort assembly
Applying eligibility criteria yielded 200 patients in the PG cohort and 233 patients in the AG cohort, resulting in an analytic sample of 433 surgically managed hip fracture cases.
2.5 Analysis strategy
Door-to-operating-room time (DTOR) was defined as the interval between emergency department registration and operating room entry. Length of stay (LOS) was defined as the interval between the placement of the admission order and the placement of the discharge order.
Descriptive statistics were generated for all variables and expressed as frequencies and percentages for categorical data or as means ± standard deviations (SD) or medians with interquartile ranges (IQR) for continuous data, as appropriate. Baseline characteristics and unadjusted outcomes were compared between the pre-DOTR (private-group) and DOTR (academic-group) periods using χ2 tests for categorical variables and Student t-tests or non-parametric equivalents for continuous variables.
Multivariable analyses were performed with generalized linear models selected according to the empirical distribution of each outcome. Binomial or multinomial link functions were applied to categorical outcomes, whereas Poisson, normal, or log-normal link functions were applied to count or continuous outcomes. Each model included covariate adjustment for age, sex, race/ethnicity, body mass index (BMI), and Charlson Comorbidity Index (CCI), as well as a binary indicator representing the study period (DOTR versus pre-DOTR). Hypothesis testing focused on the estimated coefficient of this period indicator.
Because DTOR and LOS demonstrated marked right skew, non-parametric methods were additionally employed. Mann-Whitney U tests were used to compare median DTOR and LOS, and χ2 tests were used to compare the proportions of patients with DTOR >36 h and the proportions of cases utilizing the 07:30 trauma start time. Statistical significance was defined as two-tailed p < 0.05.
Baseline equivalence between cohorts was further assessed for age, BMI, and CCI. Age and BMI were compared with Mann-Whitney U tests owing to non-normal distributions, and CCI categories (0-2, 3-5, ≥6) were compared with χ2 analysis, ensuring that subsequent differences in DTOR or LOS were not attributable to underlying differences in patient frailty or medical complexity.
All analyses were executed with SAS software (version 9.4; SAS Institute, Cary, NC).
3 Results
A total of 433 surgically managed hip fracture cases were analyzed (private-group period [PG], n = 200; academic-group period [AG], n = 233). The two cohorts were comparable before surgery. The private group's mean age was 75 ± 10 years, the mean body-mass index (BMI) was 25.5 ± 5.0 kg/m2, and the mean CCI score was 6.2 ± 2.4. For the academic group, the mean age was 74 ± 10 years, the mean BMI was 25.2 ± 5.1 kg/m2, and the mean CCI score was 6.2 ± 2.2, respectively. Non-parametric testing confirmed that age (Mann-Whitney U, p = 0.42) and BMI (Mann-Whitney U, p = 0.55) did not differ significantly between groups. Likewise, CCI distribution was not significantly different (χ2, p = 0.48). (Fig. 1).
3.1 Timeliness of surgery
Median door-to-operating-room time (DTOR) declined from 20.5 h in PG to 16.4 h in AG (Mann-Whitney U, p < 0.001). The proportion of patients with DTOR >36 h fell from 21.0 % to 6.0 % (χ2, p < 0.001), representing a nearly three-fold reduction (Table 1).
| Variable | Private (PG)(N = 200) | Academic (AG)(N = 233) | p-value |
| Door to OR time, hours, median [IQR] | 20.5 [13.6, 31.1] | 16.4 [12.7, 22.3] | <0.001 |
| 36 h or more to OR, N (%) | 42 (21.0 %) | 14 (6.0 %) | <0.001 |
| Length of hospital stay, hours, median [IQR] | 137.2 [101.6, 187.9] | 131.1 [92.9, 179.3] | 0.184 |
| Start cases | 45 (22.5 %) | 82 (35.0 %) | 0.005 |
3.2 Operating-room utilization
Utilization of the 07:30 dedicated orthopaedic trauma room increased from 22.5 % in PG to 35.0 % in AG (χ2, p = 0.005).
3.3 Length of stay
Median length of stay decreased from 137.2 h in PG to 131.1 h in AG; however, the difference was not statistically significant (Mann-Whitney U, p = 0.184).
Collectively, implementation of the academic trauma service and structured DOTR processes was associated with a significant reduction in surgical delay and improved operating room start time utilization, while maintaining comparable patient demographics and comorbidity profiles between study periods.
4 Discussion
Enhanced utilization of a dedicated orthopaedic trauma room (DOTR) at this Level III trauma center coincided with significant gains. Over the 24-month observation window, median door-to-operating-room time (DTOR) fell significantly, morning trauma-room utilization rose, and the proportion of hip-fracture patients treated beyond 36 h declined sharply, all recognized markers of improved quality of care. Baseline age, BMI, and CCI were equivalent between the private-group (PG) and academic-group (AG) cohorts, minimizing the likelihood that differences in DTOR, delayed surgery, or length of stay (LOS) were driven by the frailty of patients or by case variation. Therefore, the observed improvements seem to reflect the DOTR model and coordinated academic workflow rather than unmeasured confounding factors or simply coincidence.
The present findings support existing literature showing that DOTRs shorten time to the OR and reduce costs.3,7,8 In a 17-year Level I analysis, DOTR implementation shortened time to operating room across multiple femoral fracture subtypes and decreased hospital and ICU LOS in most groups, although at the expense of a longer emergency department LOS, which likely reflects increased transfer-in volume.9 A complementary study from the same trauma system demonstrated a different yet just as crucial downstream effect: elective arthroplasty volume rose markedly following DOTR adoption, with surgeons performing an additional 173 elective cases per year and the institution recording a statistically significant annual market share gain (p = 0.039).10 Together, these studies indicate that DOTRs improve acute fracture care and create increased daytime capacity that can be reallocated to high-value elective work, thereby enhancing both patient flow and institutional revenue.
In the current study, the proportion of patients with DTOR >36 h fell from 21 % to 6 %, a 15 percent improvement that aligns with the current guidelines to operate within 24–48 h.1 Earlier intervention is clinically relevant and linked to lower postoperative morbidity and mortality.4 While the 6.1-h LOS reduction in this study did not reach statistical significance, the trend would translate into an estimated annual saving of ∼$194,000 based on the institution's per-diem cost.
Greater trauma room utilization fosters a more efficient workflow, enabling a higher caseload during regular hours.11 In one study, even a part-time DOTR led to a decline in after-hours surgery from 32.4 % to 19.6 % (p = 0.008).12 Fewer off-hour procedures can yield net positive financial returns and liberate additional daytime capacity, seven thereby shortening wait lists, further compressing DTOR for future patients, and allowing growth in elective volume as described above.10
Reduced LOS has been associated with lower mortality and fewer long-term complications in orthopedic populations,13 particularly among hip-fracture patients.11–13 Dedicated trauma rooms have been shown to shorten time to the operating room and, in turn, decrease postoperative morbidity and surgical complications.14 Consistent with these observations, the number of hips treated more than 36 h after admission declined from 42 in PG to 14 in AG (p < 0.001).
4.1 Strengths and limitations
This study presented a unique opportunity where there was a complete change in orthopedic call coverage at a specific date at the beginning of a calendar year. This allowed for a complete change in personnel managing the orthopedic fracture care through a single emergency room. This allowed for a study where the only constant variables were the need for patient care and the availability of a morning trauma slot provided by the hospital to deliver that care. The only variable that changed was the team members providing that care.
Limitations include the study's retrospective nature, which meant relying on chart review. As a result, some details, such as small changes in physician assistant coverage or exact fracture patterns, may not have been captured. Other operating room process changes may have occurred during the study period, which may have influenced results even though no significant policy shifts were identified. Because this before/after comparison is observational, we cannot exclude residual confounding despite similar baseline demographics.
A recent survey reported that 14 of the 20 highest-ranked U.S. hospitals employ a DOTR model.4 Evidence from multiple settings along with the present Level III results supports wider adoption of dedicated trauma rooms as a best practice for emergent fracture management.
5 Conclusion
Pairing an academically staffed trauma service with a dedicated orthopaedic trauma room significantly shortened door-to-operating-room time, raised on-time start utilization, and cut the number of hip fracture cases delayed beyond 36 h. A modest, though non-significant, drop in hospital length of stay and the prospect of cost savings were also observed. These gains were achieved without changes in patient complexity, highlighting the value of streamlined workflows rather than patient-mix differences.
Community trauma centers can adopt a similar model: combining a protected morning trauma slot with coordinated multidisciplinary coverage to improve timeliness, reduce after-hours surgery, and increase capacity for elective work. The findings support dedicated trauma rooms as a practical, patient-centered strategy for enhancing hip fracture care and overall operating room efficiency.
CRediT authorship contribution statement
Lianne Wagner: Conceptualization, Data curation, Writing – review & editing, Formal analysis. Usher Khan: Writing – review & editing. Ibrahim Rababa: Writing – review & editing. Zachary Cox: Software, Investigation, Methodology. Keelan Spencer: Software, Investigation, Methodology. Alan Afsari: Supervision. Adam Fahs: Supervision. Benjamin Best: Writing – review & editing, Formal analysis, Supervision.
Ethics in publishing statement
This research presents an accurate account of the work performed, all data presented are accurate and methodologies detailed enough to permit others to replicate the work.
This manuscript represents entirely original works and or if work and/or words of others have been used, that this has been appropriately cited or quoted and permission has been obtained where necessary.
This material has not been published in whole or in part elsewhere.
The manuscript is not currently being considered for publication in another journal.
That generative AI and AI-assisted technologies have not been utilized in the writing process or if used, disclosed in the manuscript the use of AI and AI-assisted technologies and a statement will appear in the published work.
That generative AI and AI-assisted technologies have not been used to create or alter images unless specifically used as part of the research design where such use must be described in a reproducible manner in the methods section.
All authors have been personally and actively involved in substantive work leading to the manuscript and will hold themselves jointly and individually responsible for its content.
Statement
No guardian or patient consent form was needed for this study as this is non-applicable to the design of the study.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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