Ajou University Hospital is a tertiary educational medical institution located in Suwon City, South Korea, operating as a regional trauma center, equivalent to a Level 1 trauma center in the United States. The institution was selected by the Korean government as a recipient of the “Regional Trauma Center Installation Support Project” in 2013, and after a preparatory period, it officially opened in 2016, and has been operating at full capacity since then. The institution’s trauma center operates 24/7, is equipped with 2 trauma bays for emergency treatment, has 3 dedicated trauma operating rooms, an interventional radiology suite for trauma, a trauma intensive care unit (with 40 beds), and trauma-specific general wards (60 beds). Considerable effort goes into maintaining the standards and quality of care of a Level 1 trauma center and sustaining an appropriate number of trauma admissions.

A Division of Trauma Surgery operates within the Department of Surgery, and exclusively treats trauma inpatients who present in the Trauma Resuscitation Room in the regional trauma center and the Emergency Department in the regional emergency medical center. The Division of Trauma Surgery operates a dedicated trauma surgery service with an in-hospital duty system. The Division of Trauma Surgery team consists of 16 specialists exclusively dedicated to treating patients with trauma. The specialists received training in the form of a 2-year trauma fellowship program. Among them, there are 12 general surgeons, 2 cardiovascular thoracic surgeons, and 2 emergency medicine specialists who are trauma fellowship board-certified and responsible for the treatment of inpatients including trauma resuscitation, trauma surgery, critical care, and physician-staffed helicopter transfers. There is a day shift and a night shift which begin at 08:00 and 18:00, respectively. A shift is staffed by 3 surgeons, designated as the resuscitation team, from general surgery (GS), cardiothoracovascular surgery (CS), or emergency medicine (EM). On some days, all 3 surgeons may be specialists in GS; on other days, there may be 2 surgeons from GS and 1 CS or EM specialist; and on another day, the team might consist of 1 GS, 1 CS, and 1 EM specialist. The day shift personnel are designated as backup staff for the night shift. If additional staff are required due to the arrival of multiple patients during the day, the night shift personnel, who are on-call for that day, will be called in for support as a priority. In addition, there is an on-call rota consisting of 6 orthopedic specialists dedicated to treating patients with trauma, 1 neurosurgery specialist, and 3 anesthesiology specialists in the rotational duty system.

Each trauma team comprises physicians including dedicated trauma surgeons, nurses, and allied health personnel. All physicians are trained in advanced trauma life support. During a high-level response to a patient with severe injury, the team is assembled within 15 minutes of the patient’s arrival. During the prehospital phase, the trauma team is contacted directly by emergency medical services (EMS) to relay information categorically about the patient’s medical condition. If the distance is too far to travel by road, the patient is directly transported from the scene to hospital via helicopter. The trauma team conducts gatekeeping and initial resuscitations. Moreover, dedicated trauma surgeons provide definitive care such as surgery, immediate resuscitation (including hemostasis of the abdominal, pelvic, thoracic, cervical, and peripheral vessels), and care in the intensive care unit (ICU). Typically, trauma fellowship board-certified general surgeons performed damage control laparotomies and conventional laparotomies, while board-certified cardiovascular thoracic surgeons carried out damage control thoracotomies and conventional thoracotomies. Additionally, in critical situations, resuscitation procedures, including resuscitative thoracotomy, were performed by board-certified general surgeons, cardiovascular thoracic surgeons, and emergency physicians. Qualified neurosurgeons and orthopedic surgeons participate in the care of patients, and on-call specialists (such as anesthesiologists and radiologists) coordinate patient interventions as defined by the guidelines.

Using the Korea Trauma Data Bank dictionary (benchmarked against the National Trauma Data Bank in the United States), our center’s data was analyzed from January 2020 to December 2022. All trauma admissions recorded in the trauma registry were evaluated to perform a comparative analysis of the performance improvement and patient safety program implemented at the trauma center. The differences in performance and outcomes between January 2020 and December 2022 were evaluated using analysis of variance for continuous variables and the chi-square test for categorical variables. The Jonckheere–Terpstra test was used to assess the tendency of the dependent variables to increase or decrease with respect to the change in the independent variables. All statistical analyses were conducted using IBM SPSS software (Version 25; IBM Corp., Armonk, NY, USA). A p < 0.05 was considered statistically significant.

During the 3-year study period between January 2020 and December 2022, there were 9,205 patients admitted with trauma. The number of patients with severe trauma admitted to the trauma center and emergency medical center increased annually. Approximately 74% of patients with trauma were admitted to the regional trauma center. The number of patients who directly visited the trauma center increased significantly. The mean age of patients was the highest in 2022, and blunt trauma was the most predominant form of trauma in 2022. The number of patients with an Injury Severity Score ≥ 15, and those admitted to ICU increased over time; however, of the number of registered trauma patients, the proportion of patients decreased during the study period (Table 1).

The number of surgeries performed by dedicated trauma surgeons and orthopedic surgeons showed an increasing trend (Figure 1). Over 3 years, dedicated trauma surgeons performed 1,787 surgeries for 1,149 patients under general anesthesia. The average time from the trauma bay to the operating room for hypotensive patients presenting with hemorrhagic shock significantly reduced in this period (p = 0.023). Damage control surgery which included gauze packing, bowel or duct resection without anastomosis, and temporary closure, was performed for hemodynamically unstable patients. Second- and 3^rd-look surgeries were performed using the laparotomy and thoracotomy procedures. Over the 3 years 214 thoracotomies were performed, of which, 41 were cardiac surgeries. Laparotomies accounted for the largest proportion of surgeries performed by dedicated trauma surgeons. Damage control laparotomies and thoracotomies accounted for about 10% of procedures, and the number of damage control thoracotomies increased significantly during the study period (p = 0.019; Table 2).

Dedicated trauma surgeons performed laparotomies using various surgical procedures for different organs. Among the 810 patients who underwent a laparotomy, a total of 892 surgical procedures were performed (excluding those related to follow-up operations). Gastrointestinal surgery accounted for the largest proportion of surgeries, followed by surgery for the liver, pancreas, duodenum and bile duct, spleen, major vessels, and urinary tract (Table 3). For the abdominal and pelvic regions, the most frequent surgical skills were bowel or mesenteric sutures and bowel resections. Additionally, resuscitation procedures, such as resuscitative thoracotomies, resuscitative endovascular balloon occlusions, and preperitoneal pelvic packing, were performed by dedicated trauma surgeons in the trauma bay and operating room (Table 4).

Among all patients included in this study, the mortality rate, excluding deaths on arrival, remained < 5%, with no significant differences observed over the 3-year study period. However, significant differences were observed in the length of hospital stay (p = 0.005; Table 5).