Archive for June, 2016

In my last blog, I talked about the Acute Care Surgery space, highlighting where it is headed, specifically as we seek to attract new surgeons to the profession.

But in an era of surgical shortages, where millions of Americans don’t have ready access to a good surgeon, getting new physicians to join the profession is just Step 1. Step 2 is finding ways to encourage existing surgeons to stay in practice, to avoid burnout and the move to other specialties that may offer greater professional rewards and a more manageable quality of life.

Let’s start by looking at how acute care surgeons help hospitals, patients and private practice surgeons improve their practices.

The acute care surgery model offers a solution to ensure 24/7 availability in the hospital, while providing benefits to all surgeons, and most importantly, to the patients. Focusing solely upon emergency surgical care in the hospital, we care for patients who need emergency general surgery. We are available to immediately respond to any emergency surgery need from the ED. And because we are there, a community surgeon doesn’t have to get a call requiring them to come in at 2 a.m. to care for a car crash victim.

We provide all patient care including consults, covering a full-service follow-up clinic to manage those patients requiring care post discharge and perform all surgical procedures during our shift.

In some acute care surgery programs, the surgeons (all board-certified in general surgery, with many holding additional certificates, such as surgical critical care) take 24-hour shifts with the next day off. They are available to handle in-house emergencies and guarantee a response to the ED within 30 minutes when needed. In addition to surgeons, a nurse practitioner (NP) and/or physician assistant (PA) is often part of the team, rounding with the surgeons each day, coordinating care for patients and communicating with the family. They are key members of the team and play an important role in patient communication, treatment and ensure effective hand-off of the patient back to his or her primary physician.

We are a true team, experienced in the latest surgical techniques and procedures. One area of focus is the use of guidelines to ensure we provide optimal care before, during and after surgery.

When an entire surgical team is incentivized to agree and commit to evidence-based practice management guidelines, variations in care are significantly reduced. Standardizing care has repeatedly been proven to improve efficiencies and outcomes, as well as lower costs. For example:

• Reduced ED turnaround times.
• Operations are performed on a timelier basis.
• Shortened LOS, with decreased complications.

While there are many benefits to an acute care surgery model, as it is still relatively new, there are concerns and important issues to discuss with our colleagues and partners. One of the concerns is the possible erosion of private practices in the community.

However, as numerous published works have shown, this doesn’t have to be the case. In fact, an article in the Journal of the American College of Surgeonsⁱ demonstrated that despite the introduction of a busy Acute Care Surgery team, the volume of cases for private practice surgeons remained the same.

In some instances, relief from ED call has allowed some private practice surgeons to increase their surgical volume; as well as enjoy a more stable office and personal life. In short, the presence of an Acute Care Surgery team enables them to perform more elective surgery cases and can help improve their overall quality of life.

My last blog of this series will address additional advantages this model brings to surgeons.

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ⁱ Journal of the American College of Surgeons. “Acute Care Surgery: Impact on Practice and Economics of Elective Surgeons.” Preston R. Miller, M.D., FACS, et al. April 2002. (http://www.journalacs.org/article/S1072-7515(12)00073-7/abstract)

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Whether it’s a collision or an emergency appendectomy, acute care surgeons, take care of the sickest patients in the hospital. We are hospital-based surgeons who, as part of a dedicated and collaborative team, provide care to patients during their most critical times of need, 24/7.

Because we are highly trained and are at the ready when patients need us most, we help to save lives and improve outcomes.

Acute care surgery is an evolving specialty encompassing the components of trauma, critical care, and emergency general surgery. The specialty addresses one of the biggest transformations happening in the ever-changing environment of surgery. It is taking on new responsibilities for emergency surgical care, and increasing the ability to care for these patients as new techniques are developed, in the face of advancing technology. Acute care surgeons are pioneering a new approach to in-patient surgery.

The Surgical Shortage versus the Demands of Inpatient Surgery Today

Why is this transformation necessary? Patients’ emergency care can be compromised by physician shortages in the surgical suite and increased volumes in the ED, a situation that has been escalating over the last several years. In fact, more than 10 years ago, a Robert Wood Johnson Foundation (RWJF) survey found that two-thirds of EDs do not have enough surgical call coverage to meet the demand for emergency surgical care.ⁱ This ongoing problem has only grown worse. A subsequent study by RWJF of on-call specialty care found that three-quarters of EDs had inadequate surgical call coverage.ⁱⁱ

Now, with millions of Americans obtaining health coverage for the first time, hospitals across the nation are reporting that even more patients are presenting to their emergency departments, in part because these newly insured patients have trouble finding primary care physicians.ⁱⁱⁱ Taking care of these patients is exacerbated by the growing shortage of surgeons. Estimates are that there will be a shortage of 46,100 surgeons and medical specialists by 2020.^iv

Clearly, the old, traditional method of surgeons in private practice taking a call, just will not work today. There aren’t enough surgeons. Those in private practice often want to focus on their practices which are intensive enough without the “nuisance of being on call.”^v Furthermore, the demands of patient care today require responses in minutes, not hours. As the acuity of patients who are hospitalized rises, so too is their need for responsive, immediately-available teams to provide acute care surgery. Finally, within the hospital environment, all departments are required to step up their timeliness and performance in delivering care according to best practices.

A New Acute Care Surgery Model

The acute care surgery model initially arose in the academic environment as a solution to manage these patients with physiologic needs similar to trauma patients for whom access to 24/7 care could make a difference in their outcome.^{vi, vii, viii, ix, x, xi} With time, with the creation of Acute Care Surgery Fellowships and the American College of Surgeons’ (ACS) vision to bring together surgeons, resources and the infrastructure to provide 24/7 care for surgical emergencies, a new model emerged that is gaining acceptance across the nation. Implementing the acute care surgery model has proven very beneficial to patients with emergency surgery needs, reducing adverse outcomes and increasing overall positive results, improvements that are attributed to the focused care of these patients.^xii

As noted, the evolving specialty of acute care surgery encompasses trauma, critical care, and emergency general surgery. Arising to satisfy the need for emergency call coverage, acute care surgeons help speed up, standardize and improve patient care overall from the ED. The rise of on-site hospital surgeons, often acute care surgeons and frequently referred to as surgicalists, is helping mitigate the problems created from the increasingly limited number of surgeons who provide this care in the community.

Recognizing the growing national need for acute care surgeons, there are now 18 fully accredited AAST Acute Care Surgery fellowship programs focusing on this track. Acute care surgery now offers surgeons coming out of residency a new career path, one that acknowledges and rewards their skills and commitment. In an era of surgeon shortages, we must find ways to attract the best and brightest to this profession; this is an important step toward that goal.

Stay tuned for my next blog on this topic which addresses the advantages this model brings to hospitals and patients.

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ⁱ American College of Emergency Physicians. “On-call Specialist Coverage in U.S. Emergency Departments, ACEP Survey of Emergency Department Directors.” September 2004. (http://www.acep.org/workarea/DownloadAsset.aspx?id=8974)
ⁱⁱ Robert Wood Johnson Foundation. “Severe Shortage of Surgical Specialists Plagues Nation’s Emergency Departments.” Mitesh Rao, M.D., M.H.S., et al. February 10, 2011. (http://www.rwjf.org/en/library/articles-and-news/2011/02/severe-shortage-of-surgical-specialists-plagues-nations-emergenc.html)
ⁱⁱⁱ California HealthLine. “Many Newly Insured Individuals Struggle to Find Primary Care Docs.” December 8, 2014. (http://www.californiahealthline.org/articles/2014/12/8/many-newly-insured-individuals-struggle-to-find-primary-care-docs)
^iv Bonnie Darves. “Physician Shortages in the Specialties Taking a Toll.” The New England Journal of Medicine Career Center. March 2011. (http://www.nejmcareercenter.org/article/physician-shortages-in-the-specialties-taking-a-toll/)
^v Deborah Gesensway. “Surgicalists: Why Aren’t They in Your Hospital?” Today’s Hospitalist. January 2015. (http://www.todayshospitalist.com/index.php?b=articles_read&cnt=1977)
^vi Derlet RW, Richards JR. “Overcrowding in the nation’s emergency departments: complex causes and disturbing effects.” Annals of Emergency Medicine. 2000; 35:63–68.
^vii Lewin Group. “Emergency Department Overload: A Growing Crisis. The Results of the AHA Survey of Emergency Department (ED) and Hospital.” 2002.
^viii Asplin BR, Magid DJ, Rhodes KV, et al. “A conceptual model of emergency department crowding.” Annals of Emergency Medicine. 2003; 42:173–180.
^ix Scherer LA, Battistella FD. Trauma and emergency surgery: an evolutionary direction for trauma surgeons.” Journal of Trauma. 2004; 56:7–12.
^x Kim PK, Dabrowski GP, Reilly PM, et al. “Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service.” Journal of the American College of Surgeons. 2004; 199:96 –101.
^xi Capacity. Available at: http://www.hospitalconnect.com/aha/press_roominfo/content/EdoCrisisSlides.pdf. Accessed Online May 5, 2006.
^xii “Sustainability and Success of the Acute Care Surgery Model in the Nontrauma Setting.”Journal of the American College of Surgeons. Volume 219, Issue 1, Pages 90–98. (http://www.journalacs.org/article/S1072-7515(14)00220-8/fulltext)