In the event of a traumatic medical emergency, millions of Americans—especially in rural areas, home for more than 14% of Americans –don’t have access to a qualified surgeon. When an accident does occur, they have to travel miles and hours to find the care they need, putting their health at risk. Often ambulances will pass right by a community hospital to get patients to a qualified trauma care facility. It’s a loss for patients, families, hospitals and the community.
Why is there such a shortage of surgeons in rural America? There are many reasons. The American College of Surgeons notes that more than half of surgeons practicing in rural areas are nearing retirement. In addition, substantial numbers of new general surgeons choose to specialize, and because of the small number of patients in rural areas, there is not enough demand to support these specialty practices. Surgeons often choose to work in or near urban areas, where there are a wealth of professional opportunities for them and amenities, schools and resources for their families. Medical students who might consider rural surgery attend university-based surgical residencies in urban environments. Without exposure to and mentorship from rural practitioners, they often choose to stay in urban facilities.
This situation creates many challenges for hospitals and communities. Frequently elective surgeries are scheduled out of the area, while community residents often choose to simply travel to other locales for health care. Even in emergencies, patients are often diverted 50 miles or more to other facilities.
Sutter Amador Hospital, like many others in rural areas, faced the challenges of 1) recruiting top-notch surgeons, 2) serving and retaining patients in its demographic and 3) achieving long-term clinical and efficiency outcomes.
While providing a range of much needed and high-quality health care services to its patients, the hospital sought to find a way to give its patients and community access to high quality, 24/7/365 acute care surgery services. To that end, hospital leaders began an intensive effort to address their need for qualified surgeons.
They had a strong and successful model to follow. In 2007, their affiliate hospital in the Sutter system, Sutter Medical Center, Sacramento (SMCS) launched a surgicalist program with Surgical Affiliates. A five-year study of the program published in the Journal of American College of Surgeons showed it had generated significant improvements, including:
With this example of how the surgicalist program, also referred to as a surgical hospitalist program, had transformed hospital performance and addressed the surgeon shortage, Sutter Amador and Surgical Affiliates made a commitment to replicate this success with 24/7 surgical teams and a collaborative and programmatic approach that would consistently improve both patient outcomes and hospital efficiency metrics.
Three years into the program, Sutter Amador is already seeing significant outcome improvements and results.
The increase in volumes and improved metrics generated a positive ROI for the program. Additional benefits include the ability to ensure 24/7/365 call coverage; a cap on skyrocketing payments to surgeons and locum tenens companies, thus ensuring greater predictability of expenses; and improvements in the overall responsiveness and timeliness of care. All that and patient satisfaction increased as well.
The success Sutter Amador Hospital has achieved is an outstanding example of how to bring quality surgical care to rural areas. It proves that the surgicalist model works in a rural hospital environment by delivering acute care surgery based on evidence-based guidelines. The result of the model is improved quality of care, patient safety and hospital performance.
If you’re interested in learning more, please request our case study entitled “Off the Beaten Track: A Road Map for Expanding Surgical Care at Rural Hospitals” at https://www.samgi.com/news-type/case-studies/.
i Rural Health Info: https://www.ruralhealthinfo.org/states/united-states
ii New England Journal of Medicine, “Physician Shortages in the Specialties Taking a Toll, March 2011 ( http://www.nejmcareercenter.org/article/physician-shortages-in-the-specialties-taking-a-toll/)
iii The Journal of American College of Surgeons, “Sustainability and Success of the Acute Care Surgery Model in the Nontrauma Setting,” July 2014, Volume 219, Issue 1, Pages 90–98
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 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.
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)
Millions of Americans don’t have access to a qualified surgeon in the event of a trauma related medical emergency—a problem that is especially acute in rural areas. Recently, Anne Platt, FACHE and CEO of Sutter Amador Hospital, and I made a presentation at the American College of Healthcare Executives’ 2016 Congress on Healthcare Leadership on this topic.
Thousands of hospitals nationwide face the twin challenges of recruitment and retention of qualified surgeons for acute and trauma care. While the issue is especially prevalent in rural areas, it affects urban and suburban hospitals as well. Plus, the issue of recruiting surgeons is compounded by aging surgeons (average age is now over 50), while fewer graduates are entering critical care residencies.
The implications of the looming surgical shortage do not bode well for hospitals or patients.
Over-burdened surgeons are increasingly pushing back. Hospitals are constantly struggling to recruit, retain and maintain surgeons and their Trauma Center status. And, patient care can potentially suffer.
Like other hospitals in rural areas, Sutter Amador Hospital, faced the increasingly difficult issues of recruiting and retaining enough surgeons to serve the needs of its community. The hospital’s goal was to find a viable solution to ensure that both its patients and the surrounding community had access to high quality, 24/7 acute care surgery services. It also wanted a long-term solution to help it avoid losing market share, while ensuring that the solution aligned with its mission, goals and culture.
Ultimately, the hospital opted to partner with Surgical Affiliates and adopted our surgicalist model to solve its problems and address its needs. With this long-term solution, which is reproducible in other hospitals, the focus is on the creation of a team approach, coordinated and supported with processes, systems and skilled advanced practitioners (nurse practitioners and physician assistants). Surgeons are always available—24/7—for consults and acute care surgeries, while advanced practitioners support the surgical team by managing clinic, follow-up care and care coordination.
A comprehensive surgical hospitalist program benefits rural hospitals, especially for solving the challenges of recruiting surgeons and improving quality of care. Plus, the model can work for hospitals in urban environments, providing consistent surgical call coverage and improving patient safety and outcomes, while boosting results throughout the hospital.
From 2012 to 2014 Sutter Amador has:
As a result, the hospital has generated a positive ROI. By applying the acute care surgery model, which applies disciplines in trauma surgery to general surgery, hospitals can better achieve consistent, evidence-based care and improved clinical outcomes.
With increasing demand, aging of surgeons and the challenges of recruitment in many markets, the nation’s hospitals will continue to struggle to find solutions for acute and trauma surgical care. A very viable solution is to partner with outside organizations such as Surgical Affiliates to build surgicalist programs. Our model delivers a programmatic approach to general emergency surgery providing access to high quality emergency surgical care 24/7.