ORIGINAL ARTICLE
The Effect of a Change in the Surgeon Response Time Mandate
on Outcomes Within Ohio Level III Trauma Centers:
It Is All About Commitment
Angela Ingraham, MD, Rakesh Shukla, PhD, Jane Riebe, BA, CSTR, M. Margaret Knudson, MD,
Jay Johannigman, MD, and the Ohio Level III Trauma Center Consortium
Background: The American College of Surgeons Committee on Trauma
guidelines for trauma center verification stipulate that the responsible sur-
geon be present within 15 minutes of the arrival of a critically injured patient.
Recently, these guidelines were liberalized, extending the response time to
30 minutes in level III trauma centers. This study evaluated the potential
impact of this guideline change on the delivery of care at Ohio’s level III
trauma centers. We hypothesized that there would be no measurable differ-
ence in the emergency department (ED) length of stay (LOS), ED disposi-
tion, and facility mortality after enactment of this mandate, which extended
the surgeon response time from 15 minutes to 30 minutes at level III trauma
centers.
Methods: Data were collected from the trauma registries of 13 level III
trauma centers in Ohio beginning 2 years before and ending 2 years after
June 30, 2004, the day the response time was extended to 30 minutes.
Statistical analyses were completed comparing the two groups in terms of
demographic and clinical characteristics, surgeon response time, ED dispo-
sition, ED LOS, and facility mortality.
Results: A total of 1,076 patients were treated during the 4-year period. The
type of trauma, age, and Injury Severity Score were similar between the two
groups. The mean (⫾SD) surgeon response times before and after the rule
change were 14.8 minutes (⫾19.4 minutes) and 15.5 minutes (⫾22.3
minutes), respectively. The two groups also had similar ED LOS (mean ⫽
2.9, median ⫽ 2.5 for both groups), rates of transfer to higher level centers
(34.4% vs. 32.8%; p ⫽ 0.58), and facility mortality rates (10.0% vs. 11.2%;
p ⫽ 0.55).
Conclusion: The extension of the surgeon response time from 15 minutes to
30 minutes did not adversely affect the outcomes of trauma patients at Ohio’s
level III trauma centers. Furthermore, the surgeon response time was similar
before and after the rule change.
Key Words: Trauma, Trauma center verification, Level III trauma centers,
Trauma systems, Surgeon response time.
(J Trauma. 2010;68: 1038 –1043)
Submitted for publication August 11, 2009.
Accepted for publication January 15, 2010.
Copyright © 2010 by Lippincott Williams & Wilkins
From the University of Cincinnati (A.I., R.S., J.J.), Cincinnati, Ohio; Regional Trauma
Registries (J.R.), Hospital Council of Northwest Ohio, Toledo, Ohio; and Uni-
versity of California (M.M.K.), San Francisco, San Francisco, California.
Supported by Ohio Department of Public Safety.
Presented at the 39th Annual Meeting of the Western Trauma Association,
February 22–28, 2009, Crested Butte, Colorado.
Address for reprints: Angela M. Ingraham, MD, Department of Surgery, Univer-
sity of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinatti, OH 45267-
0558; e-mail: angie.ingraham@yahoo.com.
DOI: 10.1097/TA.0b013e3181d486e9
1038 The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 68, Number 5, May 2010
T he American College of Surgeons (ACS) established
guidelines for the designation of trauma centers and the
development of regional trauma systems in 1976.1 Since that
time, 38 states have passed legislation that authorizes the
development of trauma systems. Furthermore, the number of
states using a version of the ACS principles for verification of
trauma centers has increased from 30 to 34.2 Beginning in the
late 1980s, members of the Ohio ACS Committee on Trauma
and other interested individuals pursued the development of
such legislation for the state of Ohio. This effort gained
substantial headway during the late 1990s and culminated
when the Ohio legislature passed Am. Sub. H.B. 138 in May
2000. House Bill 138, “Ohio’s Trauma Bill,” legislated a
state-wide trauma system with full implementation effective
in 2002.3 The bill stipulated that if patients’ injuries met
specified criteria, then they must be transported to a trauma
center. The bill further defined a “trauma center” as a hospital
that had achieved successful verification at any level (I, II, III,
or IV) via the review process of the American College of
Surgeons Committee on Trauma (ACS COT).
The ACS COT publishes its standards of care in Re-
sources for Optimal Care of the Injured Patient.4 A key
principle is the surgeon’s presence at the bedside for the care
and resuscitation of the critically injured patient. ACS stan-
dards require that the responsible surgeon be in the emer-
gency room within 15 minutes of being notified of the arrival
of a traumatized patient for the large volume, primarily,
urban trauma centers (level I and II). However, the most
recent revision of the Resources document allows a 30-
minute response time for the lower volume, primarily,
rural level III centers.
After the passage of Ohio’s Trauma Bill in 2000, a
number of hospitals throughout the state developed and
implemented the verification review process to achieve level
III status. During the ensuing 3 years, a total of 14 Ohio
hospitals achieved verification by the ACS COT Verification
Review Committee (ACS COT VRC) as level III trauma
centers. During the developmental phase (and before the most
recent version of the ACS COT Resources document), a
number of these centers expressed concerns regarding the
ability to meet the 15-minute surgeon response criterion.
Reasons frequently cited included their relatively small vol-
ume, their lack of large attending surgeon call rosters, the
extended driving distances encountered in a more rural set-
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 68, Number 5, May 2010
ting, and the frequent transfer of the most critically ill patients
to a higher level of care. In response to this concern, the
chairman of the Ohio Committee on Trauma requested that
the ACS COT VRC extend the surgeon response time for
level III trauma centers from 15 minutes to 30 minutes. This
petition was reviewed by the members of the ACS COT VRC
and endorsed, effective in 2004. In return, members of the
ACS COT VRC requested that the level III trauma centers in
Ohio evaluate the potential impact(s) of the implementation
of this rule change. As a result, the Ohio COT submitted a
grant to the State of Ohio Emergency Medical Services/
Trauma Fund to undertake a 4-year analysis of the conse-
quences of this rule change. In this study, which presents the
results of that request from the ACS COT, we hypothesized
that there would be no measurable difference in the Emer-
gency Department (ED) length of stay (LOS), ED disposition,
and facility mortality after enactment of this mandate, which
extended the surgeon response time from 15 minutes to 30
minutes at level III trauma centers.
MATERIALS AND METHODS
At the inception of this study, 14 Ohio hospitals located
across the state in 12 different counties were ACS-verified or
functioning as a state provisional level III trauma center.
Each of these hospitals was invited to participate in this study
with 13 of the 14 hospitals accepting the request. One
hospital elected not to participate for undetermined reasons.
Business agreements were approved with each of the partic-
ipating hospitals to secure protection of the data.
All the centers that participated used one of two com-
mon registry products (TraumaBase or TraumaBasic).5 Data
were collected on patients for whom the trauma team was
activated at the highest level. Data elements compiled for this
study are listed in Table 1. The data collected from the
TABLE 1. Data Elements Identified for This Study to
Determine the Effect of Extending the Surgeon Response
Time From 15 Minutes to 30 Minutes at Ohio Level III
Trauma Centers on Emergency Department (ED) Length of
Stay, Transfer to Higher Level Center, and Facility Mortality
Injury date
Date of birth
Cause of injury E-code
Trauma type
Date and time of ED admission
Hospital arrival date and time
Date and time of trauma surgeon’s notification
Trauma surgeon’s arrival date and time
Date and time of head computed tomography
Date and time of blood transfusion
Date and time to operating room
ED disposition
ED length of stay
Discharge disposition
Hospital length of stay
Injury Severity Score
Mortality (expired vs. survived)
© 2010 Lippincott Williams & Wilkins
Change in the Surgeon Response Time Mandate
hospitals was imported into a separate trauma registry func-
tion maintained for the purpose of this study.
The 1,076 records were reviewed for completeness and
consistency in coding. Substantial variation in the frequency
and consistency of complete data existed with respect to
clinical information and certain data points, such as time to
first computed tomography (CT) scan, time to operating
room, and time to the administration of the first unit of blood.
Requests were directed to the originating hospitals in an
attempt to resolve these missing data points. Analysis also
revealed an inconsistency with respect to the reporting of the
elapsed time between the patient’s and the surgeon’s ED
arrival times. In some instances, review of the data revealed
a negative number for the surgeon’s response time (TsResp)
in cases where the trauma surgeon arrived in the ED before
the patient’s arrival. For the purpose of this study, the TsResp
was changed to 0 minutes whenever the surgeon was present
in the ED at the time of the patient’s arrival.
Descriptive statistics were obtained for demographic
and clinical characteristics, which included age, Injury Se-
verity Score (ISS), cause of trauma, and TsResp. Group 1
represents patients treated during the 2-year period before
June 30, 2004, with a 15-minute response criterion. Group 2
represents those patients treated after the response time was
extended to 30 minutes on June 30, 2004. Of note, two
centers maintained a 15-minute response time following the
rule change. For the purpose of this analysis, the data from
these two centers were categorized under group 1 even after
the rule change.
Means, medians, and standard deviations were calcu-
lated for quantitative variables; frequencies and percentages
were reported for qualitative variables. Statistical tests of
between-group comparisons were conducted both with and
without controlling for potential confounders such as age,
ISS, and type of trauma. Because the study data were natu-
rally stratified by the trauma center, analyses were also
conducted to account for possible between-hospital variations
in the endpoints using analysis of covariance for the contin-
uous outcome of ED LOS and Cochran-Mantel-Haenszel test
for categorical endpoints of facility mortality and ED dispo-
sition. We also used logistic regression analysis for the
categorical endpoints to control for potential confounders. All
statistical analyses were carried out using SAS package
version 9.1 (SAS Institute, Cary, NC).
RESULTS
A total of 1,076 patients were admitted to 13 level III
trauma centers during the 4-year study period. Six low-
volume trauma centers contributed ⬍30 patients each and
were analyzed as a single hospital. There were similar num-
bers of patients between the two groups: 539 patients in group
1 versus 537 in group 2 (Table 2). There were no significant
differences between the two groups based on age, Injury
Severity Score (ISS), or type of trauma. Age was missing for
one patient in group 2. ISS was missing for 33 patients (10
patients in group 1 and 23 patients in group 2). The mecha-
nism of injury resembles the natural occurrence of traumatic
injuries with blunt predominating over penetrating injuries.
1039
Ingraham et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 68, Number 5, May 2010

TABLE 2. Clinical Characteristics of Trauma Patients Treated at Ohio Level III Trauma Centers Before and After the Surgeon
Response Time Mandate Change
Group 1 Group 2
(Patients Treated Until June 30, 2004) (Patients Treated on or After June 30, 2004)
Variable (N ⴝ 539, 50.1%) (N ⴝ 537, 49.9%) p
Age (yr, mean 关standard deviation兴) 37.2 ⫾ 20.1 38.5 ⫾ 19.7 0.30
ISS (median, range) 9.0 (1–75.0) 10.0 (1.0–75.0) 0.87
Trauma type 0.45
Blunt 461 (85.5) 441 (82.1)
Penetrating 65 (12.1) 80 (14.9)
Burn 7 (1.3) 10 (1.9)
Other 5 (0.9) 6 (1.1)
Missing 1 (0.2) 0 (0.0)
Age was missing for one patient in group 2; Injury Severity Score (ISS) was missing for 33 patients (10 patients in group 1 and 23 patients in group 2). The comparisons were
made after log transformation of the variables (ISS) between the groups using independent t test. Fisher’s exact test was used to assess the association of categorical variables with
group.

TABLE 3. Surgeon Response Time, Emergency Department (ED) Length of Stay (LOS), ED Disposition, and Facility Mortality
of Patients Treated at Ohio Level III Trauma Centers Before and After the Surgeon Response Time Mandate Change
Group 1 Group 2
(Patients Treated Until June 30, 2004) (Patients Treated on or After June 30, 2004)
Outcome (N ⴝ 539, 50.1%) (N ⴝ 537, 49.9%) p
Surgeon response time (minutes, median 10.0 (0.0–176.0) 11.0 (0.0–257.0) 0.45
关range兴)
Emergency department length of stay (hour, 2.5 (0.0–19.9) 2.5 (0.0–22.3) 0.84
median 关range兴)
Emergency department disposition (n, %) 0.58
Transferred to higher level trauma center 185 (34.4) 176 (32.8)
Other 353 (65.4) 361 (67.2)
Mortality (n, %) 0.55
Yes 54 (10.0) 60 (11.2)
No 485 (90.0) 477 (88.8)
Response times were missing for 158 patients in group 1 and 157 patients in group 2. The ED disposition was missing for one person in group 1. The comparisons were made
after log transformation of the variables (ED LOS, surgeon response time) between the groups using independent t test. Fisher’s exact test was used to assess the association of
categorical variables with group.

The overall response time ranged from a minimum of 0
minutes to ⬎4 hours (257 minutes) (Table 3). The surgeon
response time was 14.8 minutes ⫾ 19.4 minutes (mean ⫾
SD) for group 1 versus 15.5 minutes ⫾ 22.3 minutes for
group 2 (p ⫽ 0.45). The two groups have similar distribu-
tions, medians, and standard deviations of surgeon response
times despite the fact that group 2 had increased available
time to respond compared with group 1 (Fig. 1).
ED LOS was similar between the two groups (mean ⫽
2.9, median ⫽ 2.5 for both groups) (Table 3). In addition, the
distributions of ED LOS were very similar between the two
groups (Fig. 2).
Approximately one third of all patients (n ⫽ 361) were
transferred to higher level centers (Table 3). The two groups
had remarkably similar overall transfer rates (34.4% for
group 1 vs. 32.8% for group 2; p ⫽ 0.58). The difference
between the transfer rates of group 1 and group 2 was not
significant (p ⫽ 0.72), even after controlling for other covari-
ates (age, ISS, ED LOS, hospital, trauma type, and cause
of trauma).
The facility mortality rate was 10.6%. Mortality rates
were also very similar between the two groups (10.0% in
group 1 vs. 11.2% in group 2, p ⫽ 0.55). After adjusting for
hospital, the association between facility mortality and group
(prechange vs. postchange) was also not significant (p ⫽
0.20). Furthermore, results of logistic regression modeling of
facility mortality showed that the effect of group is still not
significant (p ⫽ 0.15) after controlling for age, ISS, cause,
and type of trauma.
The overall percent of missing response times was
⬃30%. However, the overall percentage of missing response
times between the two groups was nearly identical (29.3% in
group 1 vs. 29.2% in group 2). The combined six small
centers had 40.7% of the patients’ response times missing (57
of 140).
DISCUSSION
The National Study on the Costs and Outcomes of
Trauma has documented a reduction in mortality when pa-
tients with injuries are cared for at trauma centers meeting the
ACS COT criteria.6 Although the high quality of trauma care
delivered at designated trauma centers can be attributed to
many factors, a dedicated, experienced, and readily available

1040 © 2010 Lippincott Williams & Wilkins

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 68, Number 5, May 2010 Change in the Surgeon Response Time Mandate

30

25

20
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15

10

5
Group

0
30

25

20
2

15

10

0
2.5 7.5 12.5 17.5 22.5 27.5 32.5 37.5 42.5 47.5 52.5 57.5 62.5 67.5 72.5 77.5 82.5 87.5 92.5 97.5 102.5 107.5 112.5 117.5 122.5

TSRespMins

Figure 1. Surgeons’ times to respond in minutes (TsRespMins) at Ohio level III trauma centers. Group 1, patients treated un-
der the 15-minute response criterion; group 2, patients treated under the 30-minute response criterion.

40
35

30
25
1

20
15

10
5
Group

0
40
35

30
25
2

20
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10
5

0
0 1.5 3.0 4.5 6.0 7.5 9.0 10.5 12.0 13.5 15.0 16.5 18.0 19.5 21.0 22.5

EDLOS

Figure 2. Patients’ lengths of stay (hours) in Emergency Department (EDLOS) at Ohio level III trauma centers. Group 1, pa-
tients treated under the 15-minute response criterion; group 2, patients treated under the 30-minute response criterion.

trauma surgeon is likely essential to guarantee the best
possible outcome. The importance of surgeon attendance at
the patient’s bedside is emphasized by the ACS verification
review process, which requires 80% compliance and docu-
mentation of a surgeon’s response. The issue of appropriate
surgeon response times is particularly important for rural
areas or small communities where both the trauma patient
volume and the number of general surgeons available to
cover level III centers are relatively low. In our study, we
found no significant effect of the mandate extending the
surgeon response time from 15 minutes to 30 minutes on the
ED LOS, ED disposition, or facility mortality of patients
treated at 13 level III trauma centers in Ohio.
The mean surgeon response times before and after the
rule change were striking similar (14.8 minutes vs. 15.5
minutes), indicating that the rule change did not negatively

© 2010 Lippincott Williams & Wilkins 1041

Ingraham et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 68, Number 5, May 2010
impact on this practice standard nor the surgeon’s commit-
ment to the injured trauma patient. Overall, ED LOS, a
surrogate indicator of efficiency of the trauma evaluation
process, was similar before and after the rule change. The rate
of transfer from level III centers to higher levels of care was
not adversely affected by the rule change (34.4% vs. 32.8%).
Furthermore, only one third of patients were transferred,
indicating that Ohio’s level III centers are effectively man-
aging a significant volume of trauma patients within their
own centers. Finally, facility mortality was not significantly
different before and after the rule change.
The expected response times for trauma surgeons to the
ED have been based primarily on empirical data. There exists
no prospective study to support the 15-minute response time
that is currently considered the standard at verified trauma
centers. Furthermore, the studies that do exist have been
conducted primarily in level I or level II trauma centers,
where surgeons are either in-house or in-house coverage is
initially provided by a senior surgical resident. Even in these
studies, it has been difficult to demonstrate that shorter
response times by the attending surgeon correlate with im-
proved patient outcomes. No significant difference was
detected between the observed survival and the survival
predicted by the Major Trauma Outcome Study criteria
among 3,689 patients, including a subset with severe thora-
coabdominal injuries, treated at a community level II trauma
center where trauma surgeons are allowed to take out-of-
hospital call.7 Controlling for ISS and Revised Trauma Score,
in-house versus on-call trauma surgeon status did not ad-
versely affect ED or hospital mortality at a level I trauma
center.8 At a level I trauma center in Ohio, in-house surgeons
were associated with shortened times to completion of diag-
nostic studies, therapeutic interventions, and transport to the
operating room but no difference in the length of intensive
care unit stay or mortality.9
Previous studies have documented that trauma surgeon
response times of 15 minutes or 20 minutes for out-of-
hospital surgeons were not associated with improved patient
outcomes.10,11 Surprisingly, when given sufficient warning
and accurate prehospital information, on-call trauma sur-
geons respond in either equal time or faster to the ED
compared with their in-house counterparts.12 In patients with
penetrating trauma at two level I trauma centers, a shorter
resuscitation time, reduced time to operation, but no differ-
ence in patient outcome were documented when surgeons
were in-house versus on-call.13 In a study from a level II
trauma center in northern Ohio, time to operation but not
resuscitation room time, time to CT scan, LOS, complica-
tions, or mortality was improved with the presence of an
attending surgeon in-house.14 Although level III designation
has been associated with improved quality of care provided to
both trauma and nontrauma, emergency surgery patients,15 a
study of 21 rural level III trauma hospitals found that the
immediate presence of a trauma surgeon could not be corre-
lated with improved survival.16
There are a number of limitations of this study. First, as
with any study developed from an analysis of trauma registry
data, the conclusions are only as strong as the quality of data.
1042
The methodology of this study incorporated direct download-
ing of trauma registry data to a single trauma registry func-
tion. This is an inherent strength of the study methodology
and allows analysis of the intact data sets from each individ-
ual hospital.
Second, the study is potentially biased, because the
surgeon response time was missing from the data almost 30%
of the time. The pattern of missing data points was uniformly
distributed across hospitals and across the before and after
groups. An analysis was performed to ascertain whether the
patients with missing response times had any effect on the
performance measures when comparing the two periods (be-
fore and after mandate). Instead of deleting patients with
missing response times, all outcome comparisons between
the groups were examined after adjusting for any effect
because of patients with missing response times by treating
“missingness” as a binary variable in the analysis and con-
trolling for that variable. The results are very similar to those
without adjusting for the “missingness” (data not shown).
The relatively poor documentation of response time was an
unexpected finding because the surgeon’s response time is an
important component of the ACS verification process, and all
the participating centers are ACS-verified level III trauma
centers. This observation has been shared with the participat-
ing trauma centers as well as the ACS COT VRC and serves
as a potential focus for future performance improvement
initiatives. It is also of interest to note that the six small
hospital centers (⬍30 patients for each center during the
4-year study) represented almost half of the missing data
points (41%). This suggests that for these small-volume
centers, completion of the full data set of the trauma registry
may present a challenge. One might anticipate this as a
potential problem for low-volume level III centers, because
the total number of registry entries in any given year would
be small and perhaps not a central focus for the trauma
programs at these institution.
Finally, various outcomes, including times to specific
diagnostic or therapeutic interventions (such as CT scan,
operating room, and first unit of blood), were initially con-
sidered for analysis based on the variables available within
the registry. However, the available number of therapeutic
intervention data points contained within the aggregated reg-
istry was insufficient to support meaningful analysis. Thus,
ED LOS, ED disposition, and facility mortality were the
primary focus of this work.
To the best of our knowledge, this study represents the
largest aggregate analysis of the performance of ACS-verified
level III trauma centers within a single state, and the first
article to specifically evaluate the potential impact of the
surgeon response guideline change. The results suggest that
the surgeon’s response time rule change from 15 minutes to
30 minutes did not adversely affect the ED LOS, ED dispo-
sition, or facility mortality of trauma patients meeting the
highest level activation criteria. The precedents and lessons
learned by this collaborative effort of the Ohio Committee on
Trauma and the 13 level III trauma centers prove to be of
great value to the future and continued development of
Ohio’s young and evolving trauma system. The methodology
© 2010 Lippincott Williams & Wilkins
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 68, Number 5, May 2010
and software implemented to conduct this study have been
preserved in the hope of conducting similar comparative
studies of the function of this large and robust group of level
III trauma centers. Most importantly, this study suggests that
it is not the ACS “rules” that govern the response of the
surgeons to patients with major injuries, but rather their
“commitment” to the cause: an essential element that cannot
be legislated.
ACKNOWLEDGMENTS
We acknowledge the dedication and significant com-
mitment of all the participating 13 level III trauma centers.
This study would not have been possible without their ongo-
ing commitment to care of the patient with injuries.
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