How Should a Level II Trauma Center Structure Trauma Call?
- 5 days ago
- 6 min read
One of the most important operational decisions for a Level II trauma center is determining how trauma call should be structured. The right model affects physician satisfaction, patient outcomes, recruitment, financial performance, and long-term sustainability of the trauma program.
Unlike many clinical standards, neither the American College of Surgeons (ACS) nor most state designation programs prescribe a specific trauma call model. Instead, they establish expectations for surgeon availability and response times while allowing hospitals flexibility in how those requirements are met.
As a result, trauma call structures vary considerably across the country. A model that works well for a 150-bed community hospital may be entirely inappropriate for a busy regional referral center seeing more than 3,000 trauma admissions each year.
There is no universally "best" model. Instead, hospitals should periodically evaluate whether their current approach continues to meet the needs of their patients, physicians, and organization.
(This post is primarily about Level II trauma centers because the presence of residents in Level I trauma centers offloads some of the demands on trauma surgeons.)
A Few Key Distinctions
Before we discuss common call models, it is important to note that several factors will influence the best model for a particular hospital:
Whether some or all trauma surgeons completed acute care surgery fellowship
The daily volumes of trauma and emergency general surgery (EGS) patients
Who employs the trauma surgeons
Availability of Advanced Practice Providers (APPs)
Additionally, while the ACS does not explicitly prohibit a surgeon from performing elective surgery while on trauma call, the trauma surgeon must be able to meet the required response time and provide continuous care to injured patients. If a surgeon is scrubbed into a lengthy elective case and cannot immediately respond to a trauma activation, the hospital must have a reliable mechanism to ensure trauma coverage. That is why many hospitals develop policies restricting elective cases while on trauma call, even though the ACS does not categorically ban them.
The Traditional General Surgery Call Model
Many Level II trauma centers rely on a shared general surgery call schedule. Under this model, the on-call surgeon is responsible for both trauma and EGS. Depending on the practice arrangement, the surgeon may also have clinic or elective operative responsibilities, provided trauma response requirements can still be met. Many hospitals discourage or prohibit scheduling lengthy elective cases during trauma call because of the potential conflict with trauma response.
Advantages
This model is straightforward and best for lower-volume trauma centers. It allows hospitals to maintain trauma and EGS coverage without hiring additional physicians or creating a separate trauma service.
Challenges
As trauma volume grows, however, the limitations become more apparent. The on-call surgeon may be expected to do more than is safely possible by responding to multiple trauma activations, performing emergency operations, evaluating emergency department consults, managing inpatient surgical patients, covering ICU patients, and continuing elective cases or clinic responsibilities.
Most critically, when the trauma surgeon is encumbered in the OR and cannot respond to trauma activations, designation and patient safety are at risk.
Dedicated Trauma Coverage
In a dedicated trauma service, one surgeon (or team) is assigned exclusively to the trauma service for the duration of the shift. That surgeon typically manages trauma activations, inpatient trauma patients, and trauma consults, as well as EGS if the hospital has an Acute Care Surgery model.
Importantly, elective practice is intentionally removed from that surgeon's schedule, not simply because of ACS requirements, but because the hospital has designed the service around continuous trauma availability.
Advantages
Dedicated trauma coverage often improves continuity of care and reduces disruption to elective practice. Surgeons frequently report higher job satisfaction because they are no longer attempting to manage clinic patients while responding to trauma activations. Hospitals may also find it easier to recruit surgeons interested in Acute Care Surgery careers.
Challenges
This approach requires sufficient patient volume to justify taking a surgeon away from elective revenue-producing activities. It also requires a larger physician workforce and greater financial investment from the hospital.
The Acute Care Surgery Model
An Acute Care Surgery service usually combines trauma, EGS, and surgical critical care. The surgeon is relieved of elective responsibilities so they can focus on urgent patients. Rather than maintaining separate trauma and emergency surgery call schedules, one integrated service manages all urgent surgical patients.
Advantages
This approach improves continuity of care and often leads to more predictable surgeon schedules. It is increasingly popular because many graduating surgeons are specifically trained in Acute Care Surgery fellowships.
Challenges
This model requires substantial institutional support and enough patient volume to keep the service busy throughout the day.
Separate Trauma and EGS Coverage
Some hospitals, particularly larger Level I and high-volume Level II trauma centers, separate trauma from EGS altogether. In that model one team covers trauma, a different team covers EGS, and some surgeons maintain elective practice.
This arrangement is much less common because it requires a larger surgical workforce, but it can improve efficiency in very busy centers where both trauma and emergency surgery volumes are high.
Common Questions
How Many Trauma Surgeons Should Be in the Hospital?
One of the most common questions hospitals ask is whether one trauma surgeon in the hospital is enough. For many lower-volume Level II trauma centers, a single trauma surgeon physically present or immediately available is entirely appropriate. However, as patient volume and complexity increase, a second daytime trauma surgeon often becomes necessary.
Hospitals typically begin considering a second daytime surgeon when they experience one or more of the following:
Multiple simultaneous trauma activations occurring regularly
Frequent operative trauma cases during daytime hours
High EGS volume competing with trauma patients
Large inpatient trauma census requiring extensive daily rounds
Difficulty completing clinic responsibilities because of trauma interruptions
Burnout among trauma surgeons
Does the Model Change if the Hospital has APPs?
It can. Advanced practice providers (APPs) are invaluable members of the trauma team and can offset some of the burdens on the trauma surgeon, such as rounding and documentation, discharge planning, and involvement in the initial evaluation and resuscitation of trauma patients.
A strong APP team may delay or eliminate the need for an additional trauma surgeon by improving efficiency and allowing physicians to focus on higher-acuity patients.
See an upcoming post on the role APPs play in trauma care.
What Is the Typical Shift Length for a Trauma Surgeon?
Most hospitals schedule either:
24-hour call
12-hour day and night shifts
Week-long call rotations, where one surgeon remains on call continuously for seven consecutive days
Weekend blocks, paired with weekday rotations
The best schedule often depends on the size of the surgical group. Some physicians may prefer week-long call because it allows for longer blocks of time off and reduces the frequency of work-life interruptions. Other groups often favor 24-hour shifts that distribute the workload more evenly and offer more predictable scheduling.
The best schedule is also determined by how many surgeons are in the hospital during the day, which can prohibit the 24-hour model.
What Are the Different Employment Models for Trauma Surgeons?
Hospital-Employed Trauma Surgeons
Some organizations choose to employ trauma surgeons directly rather than relying exclusively on private surgical groups. Employment allows hospitals greater control over scheduling, quality improvement participation, trauma registry documentation, committee involvement, and administrative responsibilities. The tradeoff is cost. Recruiting and employing trauma surgeons represents a significant long-term investment, particularly in competitive markets where shortages already exist.
It is important to note that not all states allow hospitals to directly employ physicians, California and Texas being the most notable states to prohibit this practice. Additionally, some public or government hospitals are required to employ physicians in certain roles, but those are institution-specific requirements rather than statewide laws.
Independent Surgical Groups with Hospital Support
Another common approach is to maintain an independent surgical practice while providing hospital financial support for trauma coverage. This hybrid model recognizes that trauma call imposes responsibilities that often extend well beyond patient care and can substantially disrupt elective practice. Compensation may include daily trauma call stipends and administrative stipends.
Regional Coverage and Locum Tenens
In rural areas, some hospitals collaborate across a region to share trauma call responsibilities. Others supplement permanent staff with locum tenens surgeons during recruitment or periods of high demand. While these approaches can help maintain coverage, they often increase costs and may reduce continuity of care.
When Is It Time to Change Your Model?
Many hospitals continue using the same trauma call structure for years because "it's always worked."
Unfortunately, physician workforce dynamics, trauma volume, reimbursement, and patient expectations change over time.
Hospitals should periodically evaluate questions such as:
Are trauma surgeons experiencing burnout?
How often are elective cases interrupted by trauma activations?
How frequently do multiple trauma patients arrive simultaneously?
Are transfers increasing?
Is emergency general surgery competing with trauma care?
Are physicians difficult to recruit or retain?
Does the hospital have sufficient APP support?
Is the current staffing model financially sustainable?
The answers often point toward opportunities to redesign trauma coverage before staffing problems become crises.
The Bottom Line on Trauma Call
There is no single trauma call structure that works for every Level II trauma center. The optimal model depends on trauma volume, patient acuity, emergency surgery workload, surgeon availability, financial resources, and long-term strategic goals.
Hospitals should resist the temptation to copy another organization's staffing model simply because it appears successful. Instead, they should conduct a thoughtful evaluation of their own data, physician workload, operational challenges, and financial performance.
