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Wachter N, Güsgen C, Geis C, Penzkofer LS, Oldhafer K, Willms AG, Huber T. Status quo of operative training in emergency surgery in Germany - results of a survey. Langenbecks Arch Surg 2024; 409:193. [PMID: 38900254 PMCID: PMC11189962 DOI: 10.1007/s00423-024-03360-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 05/22/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Emergencies and emergency surgeries are a central part of everyday surgical care in Germany. However, it is unclear how emergency surgery is practically trained in clinics on a daily basis and what training concept is underlying. Therefore, the aim of this survey study was to capture the status quo of emergency surgical training of German general and visceral surgeons. METHODS The members of the German Society for General and Visceral Surgery were surveyed online (n = 5281). The questionnaire included demographic data and expertise in surgery and assistance in emergency surgery regarding common emergency surgical operations. In addition, further training measures in emergency surgery and their support by employers were queried. RESULTS Only complete questionnaires (n = 184, response rate 3.5%) were included in the analysis. Most participants were in training (n = 69; 38%), followed by senior physicians (n = 52; 29%), specialists (n = 31; 17%) and chief physicians (n = 30; 17%). 64% of the participants were employed at university hospitals or maximum care hospitals. Regarding further training opportunities, in-clinic shock room training was most frequently used. Outside of their own clinic, the ATLS course was most frequently mentioned. Operations for cholecystitis and appendicitis as well as emergency stoma procedures are the most common emergency procedures. There was a strong difference in the frequency of operated cases depending on the level of training. For operations to treat acute abdominal traumas (hemostasis of liver and spleen, packing) as well as outside of visceral surgery, only low competence was reported. Over 90% of survey participants consider emergency surgery to be an indispensable core competence. Neither in the old (76%) nor in the new training regulations (47%) is emergency surgery adequately represented according to the participants' assessment. There was a significantly lower prevalence of the "sub-steps concept" in emergency surgery at 38% compared to elective surgery (44%). Important elements of imparting skills in emergency surgery are simulation and courses as well as operative sub-steps, according to the majority of survey participants. CONCLUSION The results show that general and visceral surgeons in Germany are introduced to emergency surgery too little structured during further training and at specialist level. The survey participants had, as expected, hardly any experience in emergency surgery outside of visceral surgery but surprisingly also little experience in visceral surgical trauma care. There is a need to discuss the future organization of emergency surgical training. Adequate simulation structures and extracurricular courses could contribute to an improvement in this respect.
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Affiliation(s)
- N Wachter
- Department of General, Visceral and Transplant Surgery, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
- Surgical Working Group Young Surgery (CAJC) of the German Society for General and Visceral Surgery (DGAV), Berlin, Germany
| | - C Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital, Koblenz, Germany
- Surgical Working Group Military and Emergency Medicine (CAMIN) of the German Society for General and Visceral Surgery (DGAV), Berlin, Germany
| | - C Geis
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital, Koblenz, Germany
- Surgical Working Group Young Surgery (CAJC) of the German Society for General and Visceral Surgery (DGAV), Berlin, Germany
| | - L S Penzkofer
- Department of General, Visceral and Transplant Surgery, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
- Surgical Working Group Young Surgery (CAJC) of the German Society for General and Visceral Surgery (DGAV), Berlin, Germany
| | - K Oldhafer
- Surgical Working Group Military and Emergency Medicine (CAMIN) of the German Society for General and Visceral Surgery (DGAV), Berlin, Germany
- Department of Surgery, Clinic of HBP-Surgery, Asklepios Klinik Barmbek, Hamburg, Germany
- Semmelweis University of Budapest Campus, Hamburg, Germany
| | - A G Willms
- Department of General and Visceral Surgery, German Armed Forces Hospital, Hamburg, Germany
- Surgical Working Group Military and Emergency Medicine (CAMIN) of the German Society for General and Visceral Surgery (DGAV), Berlin, Germany
| | - Tobias Huber
- Department of General, Visceral and Transplant Surgery, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
- Surgical Working Group Young Surgery (CAJC) of the German Society for General and Visceral Surgery (DGAV), Berlin, Germany.
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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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Murphy PB, Coleman J, Maring M, Pokrzywa C, Deshpande D, Al Tannir AH, Biesboer EA, Morris RS, Figueroa J, de Moya M. Early career acute care surgeons' priorities and perspectives: A mixed-methods analysis to better understand full-time employment. J Trauma Acute Care Surg 2023; 95:935-942. [PMID: 37418689 DOI: 10.1097/ta.0000000000004037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
BACKGROUND Understanding the expectations of early career acute care surgeons will help clarify the practice and employment models that will attract and retain high-quality surgeons, thereby sustaining our workforce. This study aimed to outline the clinical and academic preferences and priorities of early career acute care surgeons and to better define full-time employment. METHODS A survey on clinical responsibilities, employment preferences, work priorities, and compensation was distributed to early career acute care surgeons in the first 5 years of practice. A subset of agreeable respondents underwent virtual semistructured interviews. Both quantitative and thematic analysis were used to describe current responsibilities, expectations, and perspectives. RESULTS Of 471 surgeons, 167 responded (35%), the majority of whom were assistant professors within the first 3 years of practice (80%). The median desired clinical volume was 24 clinical weeks and 48 call shifts per year, 4 weeks less than their median current clinical volume. Most respondents (61%) preferred a service-based model. The top priorities cited in choosing a job were geography, work schedule, and compensation. Qualitative interviews identified themes related to defining full-time employment, first job expectations and realities, and the often-misaligned system and surgeon. CONCLUSION Understanding the perspectives of early career surgeons entering the workforce is important particularly in the field of acute care surgery where no standard workload or practice model exists. The wide variety of expectations, practice models, and schedule preferences may lead to a mismatch between surgeon desires and employment expectation. Consistent employment standards across our specialty would provide a framework for sustainability. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Patrick B Murphy
- From the Division of Trauma/Acute Care Surgery, Department of Surgery (P.B.M., C.P., A.H.A.T., E.A.B., R.S.M., J.F., M.d.M.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (J.C.), University of Louisville School of Medicine, Louisville, Kentucky; and Medical College of Wisconsin (M.M., D.D.), Milwaukee, Wisconsin
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Atwood R, Benoit P, Hennrikus W, Kraemer L, Gunasingha RM, Kindvall A, Jessie E, Gosztyla C, Bradley M. Simple signage and targeted education can lead to process improvement in acute appendicitis care. BMJ Open Qual 2023; 12:e002327. [PMID: 37879672 PMCID: PMC10603529 DOI: 10.1136/bmjoq-2023-002327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION An institution-wide protocol for uncomplicated acute appendicitis was created to improve compliance with best practices between the emergency department (ED), radiology and surgery. Awareness of the protocol was spread with the publication of a smartphone application and communication to clinical leadership. On interim review of quality metrics, poor protocol adherence in diagnostic imaging and antimicrobial stewardship was observed. The authors hypothesised that two further simple interventions would result in more efficient radiographic diagnosis and antimicrobial administration. MATERIALS AND METHODS Surgery residents received targeted in-person education on the appropriate antibiotic choices and diagnostic imaging in the protocol. Signs were placed in the emergency and radiology work areas, immediately adjacent to provider workstations highlighting the preferred imaging for patients with suspected appendicitis and the preferred antibiotic choices for those with proven appendicitis. Protocol adherence was compared before and after each intervention. RESULTS Targeted education was associated with improved antibiotic stewardship within the surgical department from 30% to 91% protocol adherence before/after intervention (p<0.005). Visible signs in the ED were associated with expedited antimicrobial administration from 50% to 90% of patients receiving antibiotics in the ED prior to being brought to the operating room before/after intervention (p<0.005). Diagnostic imaging after the placement of signs showed improved protocol adherence from 35% to 75% (p<0.005). CONCLUSION This study demonstrates that smartphone-based applications and communication among clinical leadership achieved suboptimal adherence to an institutional protocol. Targeted in-person education reinforcement and visible signage immediately adjacent to provider workstations were associated with significantly increased adherence. This type of initiative can be used in other aspects of acute care general surgery to further improve quality of care and hospital efficiency.
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Affiliation(s)
- Rex Atwood
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Patrick Benoit
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - William Hennrikus
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Laura Kraemer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Rathnayaka Mudiyanselage Gunasingha
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Angela Kindvall
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Elliot Jessie
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Carolyn Gosztyla
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Matthew Bradley
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Quality of Care for Gallstone Pancreatitis-the Impact of the Acute Care Surgery Model and Hospital-Level Operative Resources. J Gastrointest Surg 2022; 26:849-860. [PMID: 34786665 DOI: 10.1007/s11605-021-05145-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/27/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Index cholecystectomy is the standard of care for gallstone pancreatitis. Hospital-level operative resources and implementation of an acute care surgery (ACS) model may impact the ability to perform index cholecystectomy. We aimed to determine the influence of structure and process measures related to operating room access on achieving index cholecystectomy for gallstone pancreatitis. METHODS In 2015, we surveyed 2811 US hospitals on ACS practices, including infrastructure for operative access. A total of 1690 hospitals (60%) responded. We anonymously linked survey data to 2015 State Inpatient Databases from 17 states using American Hospital Association identifiers. We identified patients ≥ 18 years who were admitted with gallstone pancreatitis. Patients transferred from another facility were excluded. Univariate and multivariable regression analyses, clustered by hospital and adjusted for patient factors, were performed to examine multiple structure and process variables related to achieving an index cholecystectomy rate of ≥ 75% (high performers). RESULTS Over the study period, 5656 patients were admitted with gallstone pancreatitis and 70% had an index cholecystectomy. High-performing hospitals achieved an index cholecystectomy rate of 84.1% compared to 58.5% at low-performing hospitals. On multivariable regression analysis, only teaching vs. non-teaching hospital (OR 2.91, 95% CI 1.11-7.70) and access to dedicated, daytime operative resources (i.e., block time) vs. no/little access (OR 1.93, 95% CI 1.11-3.37) were associated with high-performing hospitals. CONCLUSIONS Access to dedicated, daytime operative resources is associated with high quality of care for gallstone pancreatitis. Health systems should consider the addition of dedicated, daytime operative resources for acute care surgery service lines to improve patient care.
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Di Pietro Martinelli C, Haltmeier T, Lavanchy JL, Perrodin SF, Candinas D, Schnüriger B. Work Characteristics of Acute Care Surgeons at a Swiss Tertiary Care Hospital: A Prospective One-Month Snapshot Study. World J Surg 2022; 46:330-336. [PMID: 34677655 PMCID: PMC8532570 DOI: 10.1007/s00268-021-06350-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Multiple acute care surgery (ACS) working models have been implemented. To optimize resources and on-call rosters, knowledge about work characteristics is required. Therefore, this study aimed to investigate the daily work characteristics of ACS surgeons at a Swiss tertiary care hospital. METHODS Single-center prospective snapshot study. In February 2020, ACS fellows prospectively recorded their work characteristics, case volume and surgical case mix for 20 day shifts and 16 night shifts. Work characteristics were categorized in 11 different activities and documented in intervals of 30 min. Descriptive statistics were applied. RESULTS A total of 432.5 working hours (h) were documented and characterized. The three main activities 'surgery,' 'patient consultations' and 'administrative work' ranged from 30.8 to 35.9% of the documented working time. A total of 46 surgical interventions were performed. In total, during day shifts, there were 16 elective and 15 emergency interventions, during night shifts 15 emergency interventions. For surgery, two peaks between 10:00 a.m.-02:00 p.m. and 08:00 p.m.-11:00 p.m. were observed. A total of 225 patient were consulted, with a first peak between 08:00 a.m. and 11:00 a.m. and a second, wider peak between 02:00 p.m. and 02:00 a.m. CONCLUSION The three main activities 'surgery,' 'patient consultations' and 'administrative work' were comparable with approximately one third of the working time each. There was a bimodal temporal distribution for both surgery and patient consultations. These results may help to improve hospital resources and on-call rosters of ACS services.
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Affiliation(s)
- Claudine Di Pietro Martinelli
- Department of Visceral Surgery und Medicine, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery und Medicine, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joël L Lavanchy
- Department of Visceral Surgery und Medicine, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stéphanie F Perrodin
- Department of Visceral Surgery und Medicine, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery und Medicine, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery und Medicine, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Cralley AL, Burlew CC, Fox CJ, Pieracci FM, Platnick KBK, Campion EM, Cohen MJ, Moore EE, Lawless RA. An Unencumbered Acute Care Surgeon Improves Delivery of Emergent Surgical Care for Cholecystectomy Patients. JSLS 2022; 26:JSLS.2022.00045. [PMID: 36212183 PMCID: PMC9521635 DOI: 10.4293/jsls.2022.00045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Many patients utilize the Emergency Room (ER) for primary care, resulting in overburdened ERs, strained resources, and delays in care. To combat this, many centers have adopted a Trauma/Acute Care Surgery (TACS) service providing specialty surgeons whose primary work is the unencumbered surgical availability to emergency surgery patients. To evaluate our programs’ efficacy, we investigated cholecystectomies as a common urgent procedure representative of services provided. We hypothesized that the adoption of a TACS service would result in improved access to care as evidence by decreased ER visits prior to cholecystectomy, improved time to cholecystectomy, and decreased hospital length of stay (LOS). Methods: All patients that underwent urgent cholecystectomy from January 1, 2018 to December 31, 2018 were reviewed. The unencumbered TACS surgeon was implemented on July 1, 2018. Prior ER visits involving biliary symptoms, time from admission to cholecystectomy, and hospital LOS were compared. Results: Of the 322 urgent cholecystectomies over the study period, 165 were performed prior and 157 following adoption of the TACS structure. The average number of ER visits for biliary symptoms prior to cholecystectomy decreased from 1.4 to 1.2 (p = 0.01). Time from admission to cholecystectomy was 28.3 hours and 27.3 hours respectively (p = 0.74). Average LOS decreased following the restructure (3.1 vs 2.5 days; p = 0.03). Conclusion: Implementation of an unencumbered TACS surgeon managing urgent surgical disease improves access to and delivery of surgical services for cholecystectomy patients in a safety net, level one trauma center. Further research is necessary to determine potential improvements in hospital cost and patient satisfaction.
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Affiliation(s)
- Alexis L. Cralley
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Clay C. Burlew
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Charles J. Fox
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Fredric M. Pieracci
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - K. Barry K. Platnick
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Eric M. Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Mitchell J. Cohen
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Ernest E. Moore
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Ryan A. Lawless
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
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Teng CY, Davis BS, Kahn JM, Rosengart MR, Brown JB. Factors associated with potentially avoidable interhospital transfers in emergency general surgery-A call for quality improvement efforts. Surgery 2021; 170:1298-1307. [PMID: 34147261 PMCID: PMC8550996 DOI: 10.1016/j.surg.2021.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency general surgery conditions are common, require urgent surgical evaluation, and are associated with high mortality and costs. Although appropriate interhospital transfers are critical to successful emergency general surgery care, the performance of emergency general surgery transfer systems remains unclear. We aimed to describe emergency general surgery transfer patterns and identify factors associated with potentially avoidable transfers. METHODS We performed a retrospective cohort study of emergency general surgery episodes in 8 US states using the 2016 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases and the American Hospital Association Annual Surveys. We identified Emergency Department-to-Inpatient and Inpatient-to-Inpatient interhospital emergency general surgery transfers. Potentially avoidable transfers were defined as discharge within 72 hours after transfer without undergoing any procedure or operation at the destination hospital. We examined transfer incidence and characteristics. We performed multilevel regression examining patient-level and hospital-level factors associated with potentially avoidable transfers. RESULTS Of 514,410 adult emergency general surgery episodes, 26,281 (5.1%) involved interhospital transfers (Emergency Department-to-Inpatient: 65.0%, Inpatient-to-Inpatient: 35.1%). Over 1 in 4 transfers were potentially avoidable (7,188, 27.4%), with the majority occurring from the emergency department. Factors associated with increased odds of potentially avoidable transfers included self-pay (versus government insurance, odds ratio: 1.26, 95% confidence interval: 1.09-1.45, P = .002), level 1 trauma centers (versus non-trauma centers, odds ratio: 1.24, 95% confidence interval: 1.05-1.47, P = .01), and critical access hospitals (versus non-critical access, odds ratio: 1.30, 95% confidence interval: 1.15-1.47, P < .001). Hospital-level factors (size, trauma center, ownership, critical access, location) accounted for 36.1% of potentially avoidable transfers variability. CONCLUSION Over 1 in 4 emergency general surgery transfers are potentially avoidable. Understanding factors associated with potentially avoidable transfers can guide research, quality improvement, and infrastructure development to optimize emergency general surgery care.
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Affiliation(s)
- Cindy Y Teng
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Billie S Davis
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh PA
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. https://twitter.com/joshua_b_brown
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Skelhorne-Gross G, Nenshi R, Jerath A, Gomez D. Structures, processes and models of care for emergency general surgery in Ontario: a cross-sectional survey. CMAJ Open 2021; 9:E1026-E1033. [PMID: 34815257 PMCID: PMC8612654 DOI: 10.9778/cmajo.20200306] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Emergency general surgery (EGS) patients require urgent surgical evaluation and intervention for various conditions, such as infectious or obstructive diseases of the gastrointestinal tract. We aimed to characterize the structures and processes that are relevant to the delivery of EGS care across Ontario hospitals and to evaluate the availability of critical resources at hospitals with formal EGS models. METHODS Between August 2019 and July 2020, we conducted a cross-sectional survey of Ontario hospitals that offered urgent general surgery (defined as the ability to provide nonelective surgical intervention within 24 to 48 hours of presentation) to adults. People with intimate knowledge of their hospital's EGS program completed a Web-based or telephone survey characterizing the program's organizational structure and staffing, operating room availability, interventional radiology and interventional endoscopy availability, intensive care unit availability and staffing, and regional participation. Their responses were compiled and comparisons were made between hospitals with and without formal EGS models of care, as well as between hospitals based on size and academic status. RESULTS Of the 114 Ontario hospitals identified, 109 responded (95.6% response rate). A third (34.6%; n = 37/107) of hospitals had EGS models of care. Thirty-four of these (91.9%) were large (> 100-bed) institutions that would be likely to have increased resources. However, even for hospitals of similar size, those with EGS models had increased staffing levels compared to those without (clinical associates 17.6% [n = 3/17] v. 10.0% [n = 2/20]; nurse practitioners or physician assistants 27.8% [n = 5/18] v. 14.3% [n = 3/21]). They also had better access to diagnostic and interventional equipment (24/7 access to computed tomography 94.1% [n = 16/17] v. 69.2% [n = 18/26]), interventional radiology (88.9% [n = 16/18] v. 42.3% [n = 11/26]), endoscopy (100% [n = 18/18] v. 69.2% [n = 18/26]) and endoscopic retrograde cholangiopancreatography (77.8% [n = 14/18] v. 42.3% [n = 11/26]), as well as dedicated operating room time (72.2% [n = 13/18] v. 0% [n = 0/25]). INTERPRETATION The structures and processes available to care for patients requiring EGS in Ontario were highly variable between hospitals. Hospitals with formal EGS models were more likely to have access to key resources.
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Affiliation(s)
- Graham Skelhorne-Gross
- Division of General Surgery (Skelhorne-Gross, Gomez), Department of Surgery, University of Toronto, Toronto, Ont.; Division of General Surgery (Nenshi), Department of Surgery, McMaster University, Hamilton, Ont.; Department of Anesthesia and Pain Medicine (Jerath), University of Toronto; Li Ka Shing Knowledge Institute (Gomez), St. Michael's Hospital; ICES Central (Jerath), Toronto, Ont
| | - Rahima Nenshi
- Division of General Surgery (Skelhorne-Gross, Gomez), Department of Surgery, University of Toronto, Toronto, Ont.; Division of General Surgery (Nenshi), Department of Surgery, McMaster University, Hamilton, Ont.; Department of Anesthesia and Pain Medicine (Jerath), University of Toronto; Li Ka Shing Knowledge Institute (Gomez), St. Michael's Hospital; ICES Central (Jerath), Toronto, Ont
| | - Angela Jerath
- Division of General Surgery (Skelhorne-Gross, Gomez), Department of Surgery, University of Toronto, Toronto, Ont.; Division of General Surgery (Nenshi), Department of Surgery, McMaster University, Hamilton, Ont.; Department of Anesthesia and Pain Medicine (Jerath), University of Toronto; Li Ka Shing Knowledge Institute (Gomez), St. Michael's Hospital; ICES Central (Jerath), Toronto, Ont
| | - David Gomez
- Division of General Surgery (Skelhorne-Gross, Gomez), Department of Surgery, University of Toronto, Toronto, Ont.; Division of General Surgery (Nenshi), Department of Surgery, McMaster University, Hamilton, Ont.; Department of Anesthesia and Pain Medicine (Jerath), University of Toronto; Li Ka Shing Knowledge Institute (Gomez), St. Michael's Hospital; ICES Central (Jerath), Toronto, Ont.
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10
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van der Wee MJL, van der Wilden G, Hoencamp R. Acute Care Surgery Models Worldwide: A Systematic Review. World J Surg 2021; 44:2622-2637. [PMID: 32377860 PMCID: PMC7326827 DOI: 10.1007/s00268-020-05536-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background The Acute Care Surgery (ACS) model was developed as a dedicated service for the provision of 24/7 nontrauma emergency surgical care. This systematic review investigated which components are essential in an ACS model and the state of implementation of ACS models worldwide. Methods A literature search was conducted using PubMed, MEDLINE, EMBASE, Cochrane library, and Web of Science databases. All relevant data of ACS models were extracted from included articles. Results The search identified 62 articles describing ACS models in 13 countries. The majority consist of a dedicated nontrauma emergency surgical service, with daytime on-site attending coverage (cleared from elective duties), and 24/7 in-house resident coverage. Emergency department coverage and operating room access varied widely. Critical care is fully embedded in the original US model as part of the acute care chain (ACC), but is still a separate unit in most other countries. While in most European countries, ACS is not a recognized specialty yet, there is a tendency toward more structured acute care. Conclusions Large national and international heterogeneity exists in the structure and components of the ACS model. Critical care is still a separate component in most systems, although it is an essential part of the ACC to provide the best pre-, intra- and postoperative care of the physiologically deranged patient. Universal acceptance of one global ACS model seems challenging; however, a global consensus on essential components would benefit any healthcare system.
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Affiliation(s)
- Mats J L van der Wee
- Alrijne Hospital, Leiderdorp, The Netherlands. .,Leiden University Medical Center, Leiden, The Netherlands.
| | - Gwendolyn van der Wilden
- Alrijne Hospital, Leiderdorp, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands
| | - Rigo Hoencamp
- Alrijne Hospital, Leiderdorp, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands.,Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.,Erasmus University Medical Center, Rotterdam, The Netherlands
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11
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Re-examining "Never Letting the Sun Rise or Set on a Bowel Obstruction" in the Era of Acute Care Surgery. J Gastrointest Surg 2021; 25:512-522. [PMID: 32043222 PMCID: PMC8278362 DOI: 10.1007/s11605-019-04496-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 12/05/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) no longer mandates urgent surgical evaluation raising the question of the role of operating room (OR) access on SBO outcomes. METHODS Data from our 2015 survey on emergency general surgery (EGS) practices, including queries on OR availability and surgical staffing, were anonymously linked to adult SBO patient data from 17 Statewide Inpatient Databases (SIDs). Univariate and multivariable associations between OR access and timing of operation, complications, length of stay (LOS), and in-hospital mortality were measured. RESULTS Of 32,422 SBO patients, 83% were treated non-operatively. Operative patients were older (median 66 vs 65 years), had more comorbidities (53% vs 46% with ≥ 3), and experienced more systemic complications (36% vs 23%), higher mortality (2.8% vs 1.4%), and longer LOS (median 10 vs 4 days). Patients had lower odds of operation if treated at hospitals lacking processes to tier urgent cases (aOR 0.90, 95% CI [0.83-0.99]) and defer elective cases (aOR 0.87 [0.80-0.94]). Patients had higher odds of operation if treated at hospitals with surgeons sometimes (aOR 1.14 [1.04-1.26]) or rarely/never (aOR 1.16 [1.06-1.26]) covering EGS at more than one location compared to always. Odds of systemic complication (OR 2.0 [1.6-2.4]), operative complication (OR 1.5 [1.2-1.8]), and mortality were increased for very late versus early operation (OR 2.6 [1.7-4.0]). CONCLUSIONS Although few patients with SBO require emergency surgery, we identified EGS structures and processes that are important for providing timely and appropriate intervention for patients whose SBO remains unresolved and requires surgery.
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12
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Santry HP, Strassels SA, Ingraham AM, Oslock WM, Ricci KB, Paredes AZ, Heh VK, Baselice HE, Rushing AP, Diaz A, Daniel VT, Ayturk MD, Kiefe CI. Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach. BMC Med Res Methodol 2020; 20:247. [PMID: 33008294 PMCID: PMC7532630 DOI: 10.1186/s12874-020-01096-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).
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Affiliation(s)
- Heena P. Santry
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 614, Columbus, OH 43210 USA
| | - Scott A. Strassels
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Angela M. Ingraham
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, Madison, WI USA
| | - Wendelyn M. Oslock
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Kevin B. Ricci
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Anghela Z. Paredes
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Victor K. Heh
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Holly E. Baselice
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Amy P. Rushing
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Adrian Diaz
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Vijaya T. Daniel
- Department of Surgery, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - M. Didem Ayturk
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - Catarina I. Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
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13
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Gantz O, Mulles S, Zagadailov P, Merchant AM. Incidence and Cost of Deep Vein Thrombosis in Emergency General Surgery Over 15 Years. J Surg Res 2020; 252:125-132. [PMID: 32278966 DOI: 10.1016/j.jss.2020.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 01/18/2020] [Accepted: 03/08/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Deep vein thromboses (DVTs) are a significant sequela of surgery and are associated with significant of morbidity and mortality in the United States. Operative emergency general surgery (EGS) cases have been demonstrated to have a greater burden of DVT than other types of surgery. MATERIALS AND METHODS DVT in EGS cases were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2015 Q3 based on ICD-9 code specification. National incidence of DVT in EGS was calculated using the National Inpatient Sample-Healthcare Cost and Utilization Project sampling methodology, and propensity score matching was used to assess costs associated with DVT. RESULTS Among 15,148,352 sample-weighted hospitalizations, 0.623% (94,392) experienced DVT. Incidence of DVT was greatest in GI ulcer surgery (1.705%) and lowest in appendectomy (0.095%). Patients with a perioperative DVT incurred $22,301 more in hospital-related costs than their counterparts who did not have a DVT. Although rates of DVT remained stable over the period analyzed, DVT-associated costs increased at a 2.09% annual rate in excess of inflation during the period analyzed. This increase in costs was most significant for laparotomy, which increased at a rate of 8.09% annually. CONCLUSIONS DVT continues to be a significant burden on resources in EGS in spite of efforts with DVT prophylaxis. Considering the increase in costs and little change in incidence, further research on cost-effective management of DVT in EGS is warranted.
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Affiliation(s)
- Owen Gantz
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Shanen Mulles
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Pavel Zagadailov
- Clinical Outcomes Research Group, CORG LLC, Grantham, New Hampshire
| | - Aziz M Merchant
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
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Bastías-Pérez M, Zagmutt S, Soler-Vázquez MC, Serra D, Mera P, Herrero L. Impact of Adaptive Thermogenesis in Mice on the Treatment of Obesity. Cells 2020; 9:E316. [PMID: 32012991 PMCID: PMC7072509 DOI: 10.3390/cells9020316] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 12/12/2022] Open
Abstract
Obesity and associated metabolic diseases have become a priority area of study due to the exponential increase in their prevalence and the corresponding health and economic impact. In the last decade, brown adipose tissue has become an attractive target to treat obesity. However, environmental variables such as temperature and the dynamics of energy expenditure could influence brown adipose tissue activity. Currently, most metabolic studies are carried out at a room temperature of 21 °C, which is considered a thermoneutral zone for adult humans. However, in mice this chronic cold temperature triggers an increase in their adaptive thermogenesis. In this review, we aim to cover important aspects related to the adaptation of animals to room temperature, the influence of housing and temperature on the development of metabolic phenotypes in experimental mice and their translation to human physiology. Mice studies performed in chronic cold or thermoneutral conditions allow us to better understand underlying physiological mechanisms for successful, reproducible translation into humans in the fight against obesity and metabolic diseases.
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Affiliation(s)
- Marianela Bastías-Pérez
- Department of Biochemistry and Physiology, School of Pharmacy and Food Sciences, Institut de Biomedicina de la Universitat de Barcelona (IBUB), Universitat de Barcelona, E-08028 Barcelona, Spain
| | - Sebastián Zagmutt
- Department of Biochemistry and Physiology, School of Pharmacy and Food Sciences, Institut de Biomedicina de la Universitat de Barcelona (IBUB), Universitat de Barcelona, E-08028 Barcelona, Spain
| | - M Carmen Soler-Vázquez
- Department of Biochemistry and Physiology, School of Pharmacy and Food Sciences, Institut de Biomedicina de la Universitat de Barcelona (IBUB), Universitat de Barcelona, E-08028 Barcelona, Spain
| | - Dolors Serra
- Department of Biochemistry and Physiology, School of Pharmacy and Food Sciences, Institut de Biomedicina de la Universitat de Barcelona (IBUB), Universitat de Barcelona, E-08028 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, E-28029 Madrid, Spain
| | - Paula Mera
- Department of Biochemistry and Physiology, School of Pharmacy and Food Sciences, Institut de Biomedicina de la Universitat de Barcelona (IBUB), Universitat de Barcelona, E-08028 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, E-28029 Madrid, Spain
| | - Laura Herrero
- Department of Biochemistry and Physiology, School of Pharmacy and Food Sciences, Institut de Biomedicina de la Universitat de Barcelona (IBUB), Universitat de Barcelona, E-08028 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, E-28029 Madrid, Spain
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Abstract
OBJECTIVE To examine national adherence to emergency general surgery (EGS) best practices. BACKGROUND There is a national crisis in access to high-quality care for general surgery emergencies. Acute care surgery (ACS), a specialty leveraging strengths of trauma systems, may ameliorate this crisis. A critical component of trauma care is adherence to clinical guidelines. We previously established best practices for EGS using RAND Appropriateness Methodology and pilot data. METHOD A hybrid (postal/electronic) questionnaire measuring adherence to 20 EGS best practices was administered to respondents overseeing EGS at all eligible adult acute care general hospitals across the US (N = 2811). Questionnaire responses were analyzed using bivariate methods and multiple logistic regression. RESULTS The response rate was 60.1%. Adherence ranged from 8.5% for having an EGS registry to 86.2% for auditing 30-day postoperative readmissions. Adherence was higher for practices not restricted to EGS (eg, auditing readmissions) compared to EGS-specific practices (eg, registry, activation system). Adopting an ACS model of care increased adherence to practices for deferring elective cases; tiering urgent operations; following National Comprehensive Cancer Network guidelines; reversing anticoagulants; auditing returns to intensive care, time to evaluation, time to operation, and time to source control; and having transfer agreements to receive patients, ICU admission protocols, as well as EGS-specific activation systems, outpatient clinics, morbidity and mortality conferences, and registries. CONCLUSIONS There is substantial room for performance improvement, and adopting an ACS model predicts better performance. This novel overview of adherence to EGS best practices will enable surgeons and policymakers to address variations in EGS care nationally.
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DiBrito SR, Bowring MG, Holscher CM, Haugen CE, Rasmussen SV, Duncan MD, Efron DT, Stevens K, Segev DL, Garonzik-Wang J, Haut ER. Acute Care Surgery for Transplant Recipients: A National Survey of Surgeon Perspectives and Practices. J Surg Res 2019; 243:114-122. [PMID: 31170553 PMCID: PMC6773475 DOI: 10.1016/j.jss.2019.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/13/2019] [Accepted: 05/01/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Transplant recipients are living longer than ever before, and occasionally require acute care surgery for nontransplant-related issues. We hypothesized that while both acute care surgeons (ACS) and transplant surgeons would feel comfortable operating on this unique patient population, both would believe transplant centers provide superior care. METHODS To characterize surgeon perspectives, we conducted a national survey of ACS and transplant surgeons. Surgeon- and center-specific demographics were collected; surgeon preferences were compared using χ2, Fisher's exact, and Kruskal-Wallis tests. RESULTS We obtained 230 responses from ACS and 204 from transplant surgeons. ACS and transplant surgeons believed care is better at transplant centers (78% and 100%), and transplant recipients requiring acute care surgery should be transferred to a transplant center (80.2% and 87.2%). ACS felt comfortable operating (97.5%) and performing laparoscopy (94.0%) on transplant recipients. ACS cited transplant medication use as the most important underlying cause of increased surgical complications for transplant recipients. Transplant surgeons felt it was their responsibility to perform acute care surgery on transplant recipients (67.3%), but less so if patient underwent transplant at a different institution (26.5%). Transplant surgeons cited poor transplanted organ resiliency as the most important underlying cause of increased surgical complications for transplant recipients. CONCLUSIONS ACS and transplant surgeons feel comfortable performing laparoscopic and open acute care surgery on transplant recipients, and recommend treating transplant recipients at transplant centers, despite the lack of supportive evidence. Elucidating common goals allows surgeons to provide optimal care for this unique patient population.
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Affiliation(s)
- Sandra R DiBrito
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Mary Grace Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarah V Rasmussen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark D Duncan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David T Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kent Stevens
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Fletcher E, Seabold E, Herzing K, Markert R, Gans A, Ekeh AP. Laparoscopic cholecystectomy in the Acute Care Surgery model: risk factors for complications. Trauma Surg Acute Care Open 2019; 4:e000312. [PMID: 31565675 PMCID: PMC6744070 DOI: 10.1136/tsaco-2019-000312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/01/2019] [Accepted: 07/06/2019] [Indexed: 02/05/2023] Open
Abstract
Background The Acute Care Surgery (ACS) model developed during the last decade fuses critical care, trauma, and emergency general surgery. ACS teams commonly perform laparoscopic cholecystectomy (LC) for acute biliary disease. This study reviewed LCs performed by an ACS service focusing on risk factors for complications in the emergent setting. Methods All patients who underwent LC on an ACS service during a 26-month period were identified. Demographic, perioperative, and complication data were collected and analyzed with Fisher’s exact test, χ2 test, and Mann-Whitney U Test. Results During the study period, 547 patients (70.2% female, mean age 46.1±18.1, mean body mass index 32.4±7.8 kg/m2) had LC performed for various acute indications. Mean surgery time was 77.9±50.2 minutes, and 5.7% of cases were performed “after hours.” Rate of conversion to open procedure was 6%. Complications seen included minor bile leaks (3.8%), infection (3.8%), retained gallstones (1.1%), organ injury (1.1%), major duct injury (0.9%), and postoperative bleeding (0.9%). Statistical analysis demonstrated significant relationships between conversion, length of surgery, age, gender, and intraoperative cholangiogram with various complications. No significant relationships were detected between complications and BMI, pregnancy, attending experience, and time of operation. Discussion Although several statistically significant relationships were identified between several risk factors and complications, these findings have limited clinical significance. Factors including attending years in practice and time of the operation were not associated with increased complications. ACS services are capable of performing a high volume of LCs for emergent indications with low complication and conversion rates. Level of evidence:IV
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Affiliation(s)
- Emily Fletcher
- Department of Surgery, Wright State Physicians, Dayton, Ohio, USA
| | - Erica Seabold
- Department of Surgery, Wright State Physicians, Dayton, Ohio, USA
| | - Karen Herzing
- Department of Surgery, Wright State Physicians, Dayton, Ohio, USA
| | - Ronald Markert
- Department of Surgery, Wright State Physicians, Dayton, Ohio, USA
| | - Alyssa Gans
- Department of Surgery, Wright State Physicians, Dayton, Ohio, USA
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Oslock WM, Paredes AZ, Baselice HE, Rushing AP, Ingraham AM, Collins C, Ricci KB, Daniel VT, Diaz A, Heh VM, Strassels SA, Santry HP. Women surgeons and the emergence of acute care surgery programs. Am J Surg 2019; 218:803-808. [PMID: 31345501 DOI: 10.1016/j.amjsurg.2019.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/26/2019] [Accepted: 07/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND In parallel to women entering general surgery training, acute care surgery (ACS) has been developing as a team-based approach to emergency general surgery (EGS). We sought to examine predictors of women surgeons in EGS generally, and ACS particularly. METHODS From our national survey, we determined the proportion of women surgeons within EGS hospitals. We compared the proportion of women surgeons based on hospitals characteristics using chi-squared tests, then used regression models to measure odds of ACS relative to the proportion of women. RESULTS 779 (50.4%) hospitals had zero women surgeons. These hospitals were more likely non-ACS and non-teaching with <200 beds. ACS had a higher median proportion of women surgeons (17%) compared to non-ACS (0%). CONCLUSION Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by more recently trained surgeons. SUMMARY Using a national survey of Emergency General Surgery (EGS) hospitals, we sought to examine predictors of women surgeons in EGS generally, and acute care surgery (ACS) particularly. We found that 779 (50.4%) hospitals had zero women surgeons. Women were more likely to be among EGS surgeons at hospitals with ACS models. Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by a higher proportion of newly trained surgeons.
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Affiliation(s)
| | - Anghela Z Paredes
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Holly E Baselice
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Amy P Rushing
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | | | - Courtney Collins
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Kevin B Ricci
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Vijaya T Daniel
- University of Massachusetts Medical School, Department of Surgery, Worcester, MA, USA
| | - Adrian Diaz
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Victor M Heh
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Scott A Strassels
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Heena P Santry
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA.
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Ricci KB, Rushing AP, Ingraham AM, Daniel VT, Paredes AZ, Diaz A, Heh VK, Baselice HE, Oslock WM, Strassels SA, Santry HP. The association between self-declared acute care surgery services and operating room access: Results from a national survey. J Trauma Acute Care Surg 2019; 87:898-906. [PMID: 31205221 DOI: 10.1097/ta.0000000000002394] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Timely access to the operating room (OR) for emergency general surgery (EGS) diseases is key to optimizing outcomes. We conducted a national survey on EGS structures and processes to examine if implementation of acute care surgery (ACS) would improve OR accessibility compared with a traditional general surgeon on call (GSOC) approach. METHODS We surveyed 2,811 acute care general hospitals in the United States capable of EGS care. The questionnaire included queries regarding structures and processes related to OR access and on the model of EGS care (ACS vs. GSOC). Associations between the EGS care model and structures and processes to ensure OR access were measured using univariate and multivariate models (adjusted for hospital characteristics). RESULTS Of 1,690 survey respondents (60.1%), 1,497 reported ACS or GSOC. 272 (18.2%) utilized an ACS model. The ACS hospitals were more likely to have more than 5 days of block time and a tiered system of booking urgent/emergent cases compared with GSOC hospitals (34.2% vs. 7.4% and 85.3% vs. 57.6%, respectively; all p values <0.001). Surgeons at ACS hospitals were more likely to be free of competing clinical duties, be in-house overnight, and cover at a single hospital overnight when covering EGS (40.1% vs. 4.7%, 64.7% vs. 25.6%, and 84.9% vs. 64.9%, respectively; all p values <0.001). The ACS hospitals were more likely to have overnight in-house scrub techs, OR nurses, and recovery room nurses (69.9% vs. 13.8%, 70.6% vs. 13.9%, and 45.6% vs. 5.4%, respectively; all p values <0.001). On multivariable analysis, ACS hospitals had higher odds of all structures and processes that would improve OR access. CONCLUSION The ACS implementation is associated with factors that may improve OR access. This finding has implications for potential expansion of EGS care models that ensure prompt OR access for the EGS diseases that warrant emergency surgery. LEVEL OF EVIDENCE Therapeutic, Level III.
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Affiliation(s)
- Kevin B Ricci
- From the Department of Surgery (K.B.R., A.P.R., A.Z.P., A.D., V.K.H., H.E.B., W.M.O., S.A.S., H.P.S.), Center for Surgical Health Assessment, Research and Policy (SHARP) (K.B.R., A.P.R., A.D., V.K.H., H.E.B., W.M.O., S.A.S., H.P.S.), Ohio State Wexner Medical Center, Columbus, Ohio; Department of Surgery (A.M.I.), University of Wisconsin, Madison, Wisconsin; Department of Surgery (V.T.D.), University of Massachusetts Medical School, Worcester, Massachusetts; and Ohio State University College of Medicine (W.M.O.), Columbus, Ohio
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20
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Santry H, Kao LS, Shafi S, Lottenberg L, Crandall M. Pro-con debate on regionalization of emergency general surgery: controversy or common sense? Trauma Surg Acute Care Open 2019; 4:e000319. [PMID: 31245623 PMCID: PMC6560666 DOI: 10.1136/tsaco-2019-000319] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 12/11/2022] Open
Abstract
More than three million patients every year develop emergency general surgical (EGS) conditions and this number is rising. EGS diseases range from straightforward to potentially life-threatening, and if severe or complex may require extensive resources. Given the looming surgeon shortage and concerns about access to care, regionalization of EGS care, in a manner similar to trauma care, has been proposed. We present a unique pro-con debate highlighting the salient arguments for and against regionalization of EGS care in the USA.
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Affiliation(s)
- Heena Santry
- Department of Surgery and Center for Surgical Health Assessment, Research and Policy, Ohio State University, Columbus, Ohio, USA
| | - Lillian S Kao
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Shahid Shafi
- Department of Surgery, Baylor Health Care System, Dallas, Texas, USA
| | - Lawrence Lottenberg
- Department of Surgery, Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Marie Crandall
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
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21
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Aizpuru M, Sweeney AP, Watson JD, Harris DG, Drucker CB, Diaz JJ, Crawford RS. Vascular Acute Care Surgery (VACS) Services: A New Model for the Future and a Solution to the Emerging Vascular Surgery Coverage Crisis. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0236-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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22
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Paine AN, Krompf BL, Borrazzo EC, Ahern TP, Malhotra AK, Norotsky MC, Tsai MH. The Impact of an Acute Care Surgery Model on General Surgery Service Productivity. ACTA ACUST UNITED AC 2018; 12:26-30. [PMID: 31131335 DOI: 10.1016/j.pcorm.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Acute Care Surgery (ACS) model has been widely adopted by hospitals across the United States, with ACS services managing emergency general surgery (EGS) patients previously treated by general surgery (GS) services. We evaluated the operational and financial impact of an ACS service model on general surgeons at an academic medical center. METHODS Using WiseOR® (Palo Alto, CA), we compared surgical case volumes for the GS service two years before (October, 2013 - September, 2015) and two years after (October, 2015 - September, 2017) implementation of an ACS service at the University of Vermont Medical Center. From financial reports, we obtained monthly wRVUs, clinical FTEs, net patient revenue, and payer mix for the GS service and compared the two years before and after ACS model implementation. RESULTS There was a significant reduction in the average number of cases performed by the GS service following ACS service implementation (monthly mean ± SD, 139.1 ± 16.0 vs. 116.7 ± 14.0, p < 0.001). The normal-hours caseload remained stable, while a significant decrease in after-hours cases accounted for the reduction in overall volume. Despite the reduction in operative volume, the decrease in mean monthly wRVU/FTE for the GS service when comparing the pre- and post- ACS periods did not reach statistical significance (614.9 ± 82.9 vs. 576.3 ± 62.1, p = 0.08).There was a significant increase in average monthly clinic-derived wRVU/FTE for the GS service (106.3 ± 13.5 vs. 120.5 ± 16.4, p = 0.007). CONCLUSIONS Shifting EGS patient management from the GS to ACS service did not negatively impact the productivity of the GS service. Background
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Affiliation(s)
- Adam N Paine
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT.,Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Bradley L Krompf
- Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Edward C Borrazzo
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT.,Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Thomas P Ahern
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT
| | - Ajai K Malhotra
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT.,Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Mitchell C Norotsky
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT.,Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Mitchell H Tsai
- Department of Anesthesiology and Department of Orthopaedics and Rehabilitation (by courtesy), The University of Vermont Larner College of Medicine, Burlington, VT
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Daniel VT, Ayturk D, Kiefe CI, Santry HP. The current State of the acute care surgery workforce: A boots on the ground perspective. Am J Surg 2018; 216:1076-1081. [PMID: 30224074 DOI: 10.1016/j.amjsurg.2018.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 08/23/2018] [Accepted: 08/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Acute care surgery (ACS) was proposed to address a general surgery workforce crisis; however, the ACS workforce composition is unknown. A national survey was conducted to determine the differences in the emergency general surgery (EGS) workforce between ACS and non-ACS hospitals. METHODS The American Hospital Association (AHA) Annual Survey of Hospitals database was queried to identify acute care general hospitals. A hybrid mail/electronic survey was sent to 2811 acute care hospitals that met the inclusion criteria of hospitals that care for adult patients (≥18 years old) with an emergency room (ER), ≥ 1 operating room (OR), and 24-h ER access. Hospitals were queried on whether they utilized an ACS model. The workforce composition among ACS and non-ACS hospitals was evaluated using X2 tests, t tests, and Wilcoxon rank-sum tests. RESULTS Survey response was 60% (N = 1690). ACS hospitals had a higher proportion of emergency surgeons who were female (20% vs. 14%, p < 0.0001), newly-trained (17% vs 10%, p < 0.0001), critical care trained (78% vs. 31%, p < 0.0001), and who had an additional degree (35% vs. 13%, p < 0.0001). More ACS hospitals had 24/7 in-house OR nursing staff (72% vs. 15%, p < 0.0001) and ancillary staff. CONCLUSIONS ACS and non-ACS hospitals differ in their surgical workforce. It is clear that ACS hospitals have more human capital, which suggests that ACS hospitals may require more dedicated resources compared to non-ACS hospitals.
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Affiliation(s)
- Vijaya T Daniel
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Didem Ayturk
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Heena P Santry
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA.
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24
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Efficiency of care and cost for common emergency general surgery conditions: Comparison by surgeon training and practice. Surgery 2018; 164:651-656. [PMID: 30098814 DOI: 10.1016/j.surg.2018.05.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/16/2018] [Accepted: 05/31/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Our institutional emergency general surgery service is staffed by both trauma and critical care-trained surgeons and other boarded general surgeons and subspecialists. We compared efficiency of care for common emergency general surgery conditions between trauma and critical care-trained surgeons and boarded general surgeons and subspecialists. METHODS Adults admitted between February 2014 and May 2017 with acute appendicitis, acute cholecystitis, intestinal obstruction, incarcerated hernia, or other acute abdominal diagnoses seen by emergency general surgery service were included. Demographic characteristics, consulting surgeon, operations, outcomes, and cost data were obtained. RESULTS A total of 1,363 patients were included: 384 (28.2%) with acute appendicitis, 477 (35.0%) with acute cholecystitis, 406 (29.8%) with intestinal obstruction, 22 (1.6%) with incarcerated hernia, and 74 (5.4%) with other acute abdominal diagnoses. Trauma and critical care-trained surgeons saw 836 (61.3%) patients. There was no difference in operative management between the two groups, however, trauma and critical care-trained surgeons had significantly less time to the operative room (7.0 vs 12.9 hours; P < .001), without a difference in duration of stay or costs. The subgroups of acute appendicitis and acute cholecystitis when treated by trauma and critical care-trained surgeons had less time to the operative room (8.4 vs 17.4 hours; P < .001), shorter hospital stay (2.5 vs 2.8 days; P = .021), and less emergency department cost ($822 vs $876; P = .012). CONCLUSION Compared with boarded general surgeons and subspecialists, trauma and critical care-trained surgeons provide more efficient care for common emergency general surgery conditions, with less time from consultation to the operative room.
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Daniel VT, Ingraham AM, Khubchandani JA, Ayturk D, Kiefe CI, Santry HP. Variations in the Delivery of Emergency General Surgery Care in the Era of Acute Care Surgery. Jt Comm J Qual Patient Saf 2018; 45:14-23. [PMID: 30093364 DOI: 10.1016/j.jcjq.2018.04.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/24/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Acute care surgery (ACS) was proposed to improve emergency general surgery (EGS) care; however, the extent of ACS model adoption in the United States is unknown. A national survey was conducted to ascertain factors associated with variations in EGS models of care, with particular focus on ACS use. METHODS A hybrid mail/electronic survey was sent in 2015 to 2,811 acute care hospitals with an emergency room and an operating room. If a respondent indicated that the approach to EGS was a dedicated clinical team whose scope encompasses EGS (± trauma, ± elective general surgery, ± burns), the hospital was considered an ACS hospital. RESULTS Survey response was 60.1% (n = 1,690); 272 (16.1%) of these hospitals reported having used an ACS model of care for EGS patients. Teaching status and general hospital practices (for example, interventional radiology available within one hour) were associated with ACS use. In bivariate analyses, ACS use was associated with many EGS-specific practices (40.1% of ACS hospitals freed their surgeons of daytime clinical responsibilities after operating overnight vs. 4.7% of general surgeon on call (GSOC) hospitals; p < 0.0001). CONCLUSION There are wide variations in EGS practices in the United States, with use of an ACS model of care being relatively low despite reported benefits of ACS models of care on EGS access, quality, and costs. Hospital factors associated with using ACS models are overall size and higher level of existing resources. These findings could be applied to the development of centers of excellence for EGS care.
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Coccolini F, Kluger Y, Ansaloni L, Moore EE, Coimbra R, Fraga GP, Kirkpatrick A, Peitzman A, Maier R, Baiocchi G, Agnoletti V, Gamberini E, Leppaniemi A, Ivatury R, Sugrue M, Sartelli M, Di Saverio S, Biffl W, Catena F. WSES worldwide emergency general surgery formation and evaluation project. World J Emerg Surg 2018; 13:13. [PMID: 29563962 PMCID: PMC5851068 DOI: 10.1186/s13017-018-0174-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 03/06/2018] [Indexed: 12/29/2022] Open
Abstract
Optimal management of emergency surgical patients represents one of the major health challenges worldwide. Emergency general surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital. EGS represents the easiest viable way to provide affordable and high-quality level of care to emergency surgical and trauma patients. It may result from the association of different physicians with other specialties in a cooperative model. The World Society of Emergency Surgery (WSES) has been working on the EGS organization and implementation since its foundation believing in the need of common benchmarks for training and educational programs throughout the world. This is a plea in different languages to all World Prime Ministers and Presidents to support the creation in all nations of an organized hub-spoke system for emergency general surgery to improve standards of care and to save lives.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, 47521 Cesena, Italy
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus Haifa, Haifa, Israel
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, 47521 Cesena, Italy
| | | | - Raul Coimbra
- Trauma Surgery, Riverside University Health System Medical Center, Riverside, CA USA
| | - Gustavo P. Fraga
- Faculdade de Ciências Médicas (FCM)—Unicamp Campinas, Campinas, SP Brazil
| | | | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Gianluca Baiocchi
- General and Emergency Surgery, Civili University Hospital, Brescia, Italy
| | | | | | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Salomone Di Saverio
- Trauma Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Walt Biffl
- Emergency and Trauma Surgery, Scripps Memorial Hospital, La Jolla, CA USA
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Khubchandani JA, Ingraham AM, Daniel VT, Ayturk D, Kiefe CI, Santry HP. Geographic Diffusion and Implementation of Acute Care Surgery: An Uneven Solution to the National Emergency General Surgery Crisis. JAMA Surg 2018; 153:150-159. [PMID: 28979986 PMCID: PMC5838713 DOI: 10.1001/jamasurg.2017.3799] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/25/2017] [Indexed: 01/14/2023]
Abstract
Importance Owing to lack of adequate emergency care infrastructure and decline in general surgery workforce, the United States faces a crisis in access to emergency general surgery (EGS) care. Acute care surgery (ACS), an organized system of trauma, general surgery, and critical care, is a proposed solution; however, ACS diffusion remains poorly understood. Objective To investigate geographic diffusion of ACS models of care and characterize the communities in which ACS implementation is lagging. Design, Setting, and Participants A national survey on EGS practices was developed, tested, and administered at all 2811 US acute care hospitals providing EGS to adults between August 2015 and October 2015. Surgeons responsible for EGS coverage at these hospitals were approached. If these surgeons failed to respond to the initial survey implementation, secondary surgeons or chief medical officers at hospitals with only 1 general surgeon were approached. Interventions Survey responses on ACS implementation were linked with geocoded hospital data and national census data to determine geographic diffusion of and access to ACS. Main Outcomes and Measures We measured the distribution of hospitals with ACS models of care vs those without over time (diffusion) and by US counties characterized by sociodemographic characteristics of county residents (access). Results Survey response rate was 60% (n = 1690); 272 responding hospitals had implemented ACS by 2015, steadily increasing from 34 in 2001 to 125 in 2010. Acute care surgery implementation has not been uniform. Rural regions have limited ACS access, with hospitals in counties with greater than the 75th percentile population having 5.4 times higher odds (95% CI, 1.66-7.35) of implementing ACS than hospitals in counties with less than 25th percentile population. Communities with greater percentages of adults without a college degree also have limited ACS access (OR, 3.43; 95% CI, 1.81-6.48). However, incorporating EGS into ACS models may be a potential equalizer for poor, black, and Hispanic communities. Conclusions and Relevance Understanding and addressing gaps in ACS implementation across communities will be crucial to ensuring health equity for US residents experiencing general surgery emergencies.
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Affiliation(s)
| | | | - Vijaya T. Daniel
- University of Massachusetts Medical School, Department of Surgery, Worcester
| | - Didem Ayturk
- University of Massachusetts Medical School, Department of Surgery, Worcester
| | - Catarina I. Kiefe
- University of Massachusetts Medical School, Department of Quantitative Health Sciences, Worcester
| | - Heena P. Santry
- University of Massachusetts Medical School, Department of Surgery, Worcester
- University of Massachusetts Medical School, Department of Quantitative Health Sciences, Worcester
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Murphy PB, DeGirolamo K, Van Zyl TJ, Allen L, Haut E, Leeper WR, Leslie K, Parry N, Hameed M, Vogt KN. Impact of the Acute Care Surgery Model on Disease- and Patient-Specific Outcomes in Appendicitis and Biliary Disease: A Meta-Analysis. J Am Coll Surg 2017; 225:763-777.e13. [PMID: 28918345 DOI: 10.1016/j.jamcollsurg.2017.08.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/13/2017] [Accepted: 08/14/2017] [Indexed: 12/29/2022]
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29
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Sugrue M, Maier R, Moore EE, Boermeester M, Catena F, Coccolini F, Leppaniemi A, Peitzman A, Velmahos G, Ansaloni L, Abu-Zidan F, Balfe P, Bendinelli C, Biffl W, Bowyer M, DeMoya M, De Waele J, Di Saverio S, Drake A, Fraga GP, Hallal A, Henry C, Hodgetts T, Hsee L, Huddart S, Kirkpatrick AW, Kluger Y, Lawler L, Malangoni MA, Malbrain M, MacMahon P, Mealy K, O'Kane M, Loughlin P, Paduraru M, Pearce L, Pereira BM, Priyantha A, Sartelli M, Soreide K, Steele C, Thomas S, Vincent JL, Woods L. Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland. World J Emerg Surg 2017; 12:47. [PMID: 29075316 PMCID: PMC5651635 DOI: 10.1186/s13017-017-0158-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/13/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.
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Affiliation(s)
- M Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - R Maier
- Department of Surgery, University of Washington, Seattle, USA.,Harborview Medical Center, Seattle, USA
| | | | - M Boermeester
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - F Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | - F Coccolini
- Department of Emergency, General and Transplant Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - A Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - A Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - G Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - L Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - F Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - P Balfe
- Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland
| | - C Bendinelli
- Department of Surgery, John Hunter Hospital, Newcastle, NSW Australia
| | - W Biffl
- Acute Care Surgery, The Queens Medical Center, Honolulu, HI USA
| | - M Bowyer
- Department of Surgery, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD USA
| | - M DeMoya
- Department of Trauma/Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - S Di Saverio
- Maggiore Hospital of Bologna, AUSL, Bologna, Italy
| | - A Drake
- Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - G P Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - A Hallal
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - C Henry
- National Clinical Advisor for the Acute Hospitals Division, Health Service Executive, Dublin, Ireland
| | - T Hodgetts
- Trauma Governance, UK Defence Medical Services, Lichfield, UK
| | - L Hsee
- Department of Trauma and Acute Care Surgery, Auckland City Hospital, Auckland, New Zealand
| | - S Huddart
- Department of Anaesthesiology, Royal Surrey County Hospital, Guildford, UK
| | - A W Kirkpatrick
- Department of Surgery, Critical Care Medicine and Regional Trauma Service, Foothills Medical Centre, Calgary, AB Canada
| | - Y Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - L Lawler
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - M Malbrain
- Intensive Care Unit and High Burn Unit, ZNA "Ziekenhuis Netwerk Antwerpen" Stuivenberg and ZNA St-Erasmus hospitals, Antwerp, Belgium
| | - P MacMahon
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - K Mealy
- Department of Surgery, Wexford University Hospital, Wexford, Ireland
| | - M O'Kane
- Department of Pathology, Altnagelvin Hospital, Londonderry, UK
| | - P Loughlin
- Department of Surgery, Altnagelvin Hospital, Londonderry, UK
| | - M Paduraru
- Department of General and Emergency Surgery, Milton Keys, UK
| | - L Pearce
- Northwest Research Collaborative, Manchester, UK
| | - B M Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - A Priyantha
- Department of Gastroenterology, Teaching Hospital, South, Colombo, Sri Lanka
| | - M Sartelli
- Department of Surgery, Macerata Hospital, Macerata, Italy
| | - K Soreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - C Steele
- Department of Gastroenterology, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - S Thomas
- Department of Trauma Services, Memorial Hospital of South Bend, Indiana, USA
| | - J L Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de bruxelles, Brussels, Belgium
| | - L Woods
- Department of Acute Hospitals, Health Services Executive, Dublin, Ireland
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A Comparison of Mortality Following Emergency Laparotomy Between Populations From New York State and England. Ann Surg 2017; 266:280-286. [DOI: 10.1097/sla.0000000000001964] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Jurkovich GJ, Davis KA, Becher RD, Burlew CC, de Moya M, Dente CJ, Galante JM, Goodwin II JS, Joseph B, Pandit V. In brief. Curr Probl Surg 2017. [DOI: 10.1067/j.cpsurg.2017.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Farrell M, Murphy E, Caplan R, Bradley K, Rubino M, Cipolle M. Management of Appendicitis with the Implementation of an Acute Care Surgery Service in a Community Teaching Hospital. Am Surg 2017. [DOI: 10.1177/000313481708300717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Acute care surgery and emergency general surgery: Addition by subtraction. J Trauma Acute Care Surg 2017; 81:131-6. [PMID: 26891159 DOI: 10.1097/ta.0000000000001016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The formation of Acute Care Surgery services leads to decreased time to treatment and improved outcomes for emergency general surgery (EGS) patients. However, minimal work has focused on the ideal care delivery system and team structure. We hypothesize that the implementation of a dedicated EGS team (separate from trauma and surgical critical care), with EGS-specific protocols and dedicated operating room (OR) time, will increase productivity and improve mortality. METHODS This is a retrospective review of financial and EGS registry data from fiscal year (FY) 12 to FY15. Data are from an academic, university-based EGS team composed of two acute care surgery attending surgeons, advanced practitioners (APs), residents, and a fellow. In FY12, processes were implemented to standardize paging of consults, patient sign-out with attending surgeons' and APs' participation, clinical/billing protocols, OR availability, and quality improvement. Outcomes included relative value units (RVUs), surgical case volume, charges/payments, and number of patient encounters. The secondary outcome was mortality. The χ test was used to compare mortality, and p < 0.05 was considered significant. RESULTS Total patient encounters increased from 6,723 in FY 12 to 9,238 in FY 15 (+37%). Relative value units increased from 18,422 in FY 12 to 25,314 in FY 15 (+37%). Charges increased by 76% and payments increased by 60% from FY 12 to FY 15. Charges per encounter increased from $461 in FY 12 to $591 in FY 15 (+28%) Additionally, both inpatient and surgical case loads increased. Mortality remained stable throughout the study period (FY 12, 4.5%; FY 13, 5.2%; FY 14, 5.3%; FY 15, 3.2%: p = 0.177). CONCLUSIONS Implementation of dedicated OR time, defined EGS team structure, practice protocols, and active attending surgeons'/APs' participation was temporally related to increased case volume, patients seen, and revenue, while mortality remained unchanged. Further study is necessary to establish the translatability of these data to other systems. LEVEL OF EVIDENCE Economic/decision, level III.
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Napolitano LM, Biester TW, Jurkovich GJ, Buyske J, Malangoni MA, Lewis FR. General surgery resident rotations in surgical critical care, trauma, and burns: what is optimal for residency training? Am J Surg 2016; 212:629-637. [PMID: 27634425 DOI: 10.1016/j.amjsurg.2016.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are no specific Accreditation Council for Graduate Medical Education General Surgery Residency Program Requirements for rotations in surgical critical care (SCC), trauma, and burn. We sought to determine the experience of general surgery residents in SCC, trauma, and burn rotations. METHODS Data analysis of surgical rotations of American Board of Surgery general surgery resident applicants (n = 7,299) for the last 8 years (2006 to 2013, inclusive) was performed through electronic applications to the American Board of Surgery Qualifying Examination. Duration (months) spent in SCC, trauma, and burn rotations, and postgraduate year (PGY) level were examined. RESULTS The total months in SCC, trauma and burn rotations was mean 10.2 and median 10.0 (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of a general surgery resident's training. However, there was great variability (range 0 to 29 months). SCC rotation duration was mean 3.1 and median 3.0 months (SD 2, min to max: 0 to 15), trauma rotation duration was mean 6.3 and median 6.0 months (SD 3.5, min to max: 0 to 24), and burn rotation duration was mean 0.8 and median 1.0 months (SD 1.0, min to max: 0 to 6). Of the total mean 10.2 months duration, the longest exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5. PGY-5 residents spent a mean of 1 month in SCC, trauma, and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1 to 3) in SCC and trauma rotations. CONCLUSIONS There is significant variability in total duration of SCC, trauma, and burn rotations and PGY level in US general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma, and burn rotations, it is an ideal time to determine the optimal curriculum and duration of these important rotations for general surgery residency training.
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Affiliation(s)
| | | | | | - Jo Buyske
- American Board of Surgery, Philadelphia, PA, USA
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Scarborough JE, Schumacher J, Pappas TN, McCoy CC, Englum BR, Agarwal SK, Greenberg CC. Which Complications Matter Most? Prioritizing Quality Improvement in Emergency General Surgery. J Am Coll Surg 2016; 222:515-24. [PMID: 26916129 PMCID: PMC5131647 DOI: 10.1016/j.jamcollsurg.2015.12.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 12/16/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Because preoperative risk factor modification is generally not possible in the emergency setting, complication prevention represents an important focus for quality improvement in emergency general surgery (EGS). The objective of our study was to determine the overall impact that specific postoperative complications have in this patient population. STUDY DESIGN Our study sample consisted of patients from the 2012-2013 ACS-NSQIP database who underwent an EGS procedure. We used population attributable fractions (PAFs) to estimate the overall impact that each of 8 specific complications had on 30-day physiologic and resource use outcomes in our study population. The PAF represents the percentage reduction in a given outcome that would be anticipated if a complication were able to be completely prevented in our study population. Both unadjusted and risk-adjusted PAFs were calculated. RESULTS There were 79,183 patients included for analysis. The most common complications in these patients were bleeding (6.2%), incisional surgical site infection (SSI) (3.4%), pneumonia (2.7%), and organ/space SSI (2.6%). Bleeding was the complication with the greatest overall impact on mortality and end-organ dysfunction, demonstrating an adjusted PAF of 10.7% (95% CI 8.2%,13.1%, p < 0.001) and 15.9% (95% CI 13.9%, 16.7%, p < 0.001) for these respective outcomes. The only other complication with a sizeable impact on these outcomes was pneumonia (adjusted PAF of 7.9% for mortality and 13.2% for pneumonia). In contrast, complications such as urinary tract infection, venous thromboembolism, myocardial infarction, and incisional SSI had negligible impacts on these outcomes. CONCLUSIONS Our study provides a framework for the development of high-value quality initiatives in EGS.
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Affiliation(s)
- John E Scarborough
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Jessica Schumacher
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Brian R Englum
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Suresh K Agarwal
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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The impact of acute care surgery on appendicitis outcomes: Results from a national sample of university-affiliated hospitals. J Trauma Acute Care Surg 2015. [PMID: 26218698 DOI: 10.1097/ta.0000000000000732] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute appendicitis is the most common indication for emergency general surgery (EGS) in the United States. We examined the role of acute care surgery (ACS) on interventions and outcomes for acute appendicitis at a national sample of university-affiliated hospitals. METHODS We surveyed senior surgeons responsible for EGS coverage at University HealthSystems Consortium hospitals, representing more than 90% of university-affiliated hospitals in the United States. The survey elicited data on resources allocated for EGS during 2013. Responses were linked to University HealthSystems Consortium outcomes data by unique hospital identifiers. Patients treated at hospitals reporting hybrid models for EGS coverage were excluded. Differences in interventions and outcomes between patients with acute appendicitis treated at ACS hospitals versus hospitals with a general surgeon on-call model (GSOC) were analyzed using univariate comparisons and multivariable logistic regression models adjusted for patient demographics, clinical acuity, and hospital characteristics. RESULTS We found 122 hospitals meeting criteria for analysis where 2,565 patients were treated for acute appendicitis. Forty-eight percent of hospitals had an ACS model (n = 1,414), and 52% had a GSOC model (n = 1,151). Hospitals with ACS models were more likely to treat minority patients than those with GSOC models. Patients treated at ACS hospitals were more likely to undergo laparoscopic appendectomy. In multivariable modeling of patients who had surgery (n = 2,258), patients treated at ACS hospitals had 1.86 (95% confidence interval, 1.23-2.80) greater odds of undergoing laparoscopic appendectomy. CONCLUSION In an era when laparoscopic appendectomy is increasingly accepted for treating uncomplicated acute appendicitis, particularly in low-risk patients, it is concerning that patients treated at GSOC model hospitals are more likely to undergo traditional open surgery at the time of presentation. Furthermore, hospitals with ACS are functioning as safety-net hospitals for vulnerable patients with acute appendicitis. LEVEL OF EVIDENCE Therapeutic study, level IV.
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