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Vadlakonda A, Cho NY, Tran Z, Curry J, Sakowitz S, Balian J, Coaston T, Tillou A, Benharash P. Demystifying the association of center-level operative trauma volume and outcomes of emergency general surgery. Surgery 2024; 176:357-363. [PMID: 38760230 DOI: 10.1016/j.surg.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/16/2024] [Accepted: 03/21/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Recent studies have demonstrated a positive volume-outcome relationship in emergency general surgery. Some have advocated for the sub-specialization of emergency general surgery independent from trauma. We hypothesized inferior clinical outcomes of emergency general surgery with increasing center-level operative trauma volume, potentially attributable to overall hospital quality. METHODS Adults (≥18 years) undergoing complex emergency general surgery operations (large and small bowel resection, repair of perforated peptic ulcer, lysis of adhesions, laparotomy) were identified in the 2016 to 2020 Nationwide Readmissions Database. Multivariable risk-adjusted models were developed to evaluate the association of treatment at a high-volume trauma center (reference: low-volume trauma center) with clinical and financial outcomes after emergency general surgery. To evaluate hospital quality, mortality among adult hospitalizations for acute myocardial infarction was assessed by hospital trauma volume. RESULTS Of an estimated 785,793 patients undergoing a complex emergency general surgery operation, 223,116 (28.4%) were treated at a high-volume trauma center. Treatment at a high-volume trauma center was linked to 1.19 odds of in-hospital mortality (95% confidence interval 1.12-1.27). Although emergency general surgery volume was associated with decreasing predicted risk of mortality, increasing trauma volume was linked to an incremental rise in the odds of mortality after emergency general surgery. Secondary analysis revealed increased mortality for admissions for acute myocardial infarction with greater trauma volume. CONCLUSION We note increased mortality for emergency general surgery and acute myocardial infarction in patients receiving treatment at high-volume trauma centers, signifying underlying structural factors to broadly affect quality. Thus, decoupling trauma and emergency general surgery services may not meaningfully improve outcomes for emergency general surgery patients. Our findings have implications for the evolving specialty of emergency general surgery, especially for the safety and continued growth of the acute care surgery model.
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Affiliation(s)
- Amulya Vadlakonda
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Nam Yong Cho
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Zachary Tran
- Department of Surgery, Loma Linda University Health, Loma Linda, CA
| | - Joanna Curry
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Sara Sakowitz
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Jeffrey Balian
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Troy Coaston
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Areti Tillou
- Division of Trauma and Acute Care Surgery, University of California, Los Angeles, CA
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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2
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de'Angelis N, Marchegiani F, Schena CA, Khan J, Agnoletti V, Ansaloni L, Barría Rodríguez AG, Bianchi PP, Biffl W, Bravi F, Ceccarelli G, Ceresoli M, Chiara O, Chirica M, Cobianchi L, Coccolini F, Coimbra R, Cotsoglou C, D'Hondt M, Damaskos D, De Simone B, Di Saverio S, Diana M, Espin-Basany E, Fichtner-Feigl S, Fugazzola P, Gavriilidis P, Gronnier C, Kashuk J, Kirkpatrick AW, Ammendola M, Kouwenhoven EA, Laurent A, Leppaniemi A, Lesurtel M, Memeo R, Milone M, Moore E, Pararas N, Peitzmann A, Pessaux P, Picetti E, Pikoulis M, Pisano M, Ris F, Robison T, Sartelli M, Shelat VG, Spinoglio G, Sugrue M, Tan E, Van Eetvelde E, Kluger Y, Weber D, Catena F. Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper. World J Emerg Surg 2023; 18:11. [PMID: 36707879 PMCID: PMC9883976 DOI: 10.1186/s13017-023-00476-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS. METHODS This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements. RESULTS Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20-107) depending on the initial surgeon's experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon's proficiency. CONCLUSIONS Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research.
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Affiliation(s)
- Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, Paris, France.
- Faculty of Medicine, University of Paris Est, UPEC, Créteil, France.
| | - Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, Paris, France
| | - Carlo Alberto Schena
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, Paris, France
| | - Jim Khan
- Department of Colorectal Surgery, Queen Alexandra Hospital, University of Portsmouth, Southwick Hill Road, Cosham, Portsmouth, UK
| | | | - Luca Ansaloni
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Paolo Pietro Bianchi
- Division of General and Robotic Surgery, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Walter Biffl
- Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Graziano Ceccarelli
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Mircea Chirica
- Department of Digestive Surgery and Liver Transplantation, Michallon Hospital, Grenoble University, Grenoble, France
| | - Lorenzo Cobianchi
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | | | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint-Germain-en-Laye Hospitals, Poissy, France
| | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | - Michele Diana
- Digestive and Endocrine Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Eloy Espin-Basany
- Department of General Surgery, Hospital Valle de Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center University of Freiburg, Freiburg, Germany
| | - Paola Fugazzola
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Paschalis Gavriilidis
- Department of HBP Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Caroline Gronnier
- Eso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Pessac, France
| | - Jeffry Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew W Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Michele Ammendola
- Digestive Surgery Unit, Health of Science Department, "Magna Graecia" University Medical School, "Mater Domini" Hospital, Catanzaro, Italy
| | | | - Alexis Laurent
- Faculty of Medicine, University of Paris Est, UPEC, Créteil, France
- Unit of HPB and Service of General Surgery, Henri Mondor University Hospital, Creteil, France
| | - Ari Leppaniemi
- Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mickaël Lesurtel
- Department of HPB Surgery and Liver Transplantation, AP-HP Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Riccardo Memeo
- Unit of Hepato-Pancreato-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, Federico II" University of Naples, Naples, Italy
| | - Ernest Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Nikolaos Pararas
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Andrew Peitzmann
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick Pessaux
- Visceral and Digestive Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France
- Institute for Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
- Institute of Viral and Liver Disease, INSERM U1110, Strasbourg, France
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Michele Pisano
- 1St General Surgery Unit, Department of Emergency, ASST Papa Giovanni Hospital Bergamo, Bergamo, Italy
| | - Frederic Ris
- Division of Digestive Surgery, University Hospitals of Geneva and Medical School, Geneva, Switzerland
| | - Tyler Robison
- Minimally Invasive Surgery Fellow, Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Giuseppe Spinoglio
- IRCAD Faculty Member Robotic and Colorectal Surgery- IRCAD, Strasbourg, France
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Donegal, Ireland
| | - Edward Tan
- Department of Surgery, Trauma Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Dieter Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, Cesena, Italy
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3
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Fransvea P, Fico V, Cozza V, Costa G, Lepre L, Mercantini P, La Greca A, Sganga G. Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study. Eur J Trauma Emerg Surg 2021; 48:1177-1188. [PMID: 33738537 DOI: 10.1007/s00068-021-01645-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA). METHODS The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality. RESULTS 182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications. CONCLUSIONS Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.
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Affiliation(s)
- Pietro Fransvea
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Valeria Fico
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Valerio Cozza
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Gianluca Costa
- Surgery Center, Campus Bio-Medico University Hospital, University Campus Bio-Medico of Rome, Rome, Italy
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Teaching Hospital, Sapienza University of Roma, Rome, Italy
| | - Luca Lepre
- General Surgery Unit, Santo Spirito in Sassia Hospital, ASL Roma 1, Rome, Italy
| | - Paolo Mercantini
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Teaching Hospital, Sapienza University of Roma, Rome, Italy
| | - Antonio La Greca
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
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4
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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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5
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Eaton BC, Vesselinov R, Ahmeti M, Stansbury JJ, Regner J, Sadler C, Nevarez S, Lissauer M, Stout L, Harmon L, Glassett B, Hampton DA, Castro HJ, Cunningham K, Mulkey S, O'Meara L, Dia JJ, Bruns BR. Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey. Am Surg 2020; 87:971-978. [PMID: 33295188 DOI: 10.1177/0003134820956929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings. METHODS Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact. RESULTS Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment. CONCLUSION This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.
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Affiliation(s)
- Barbara C Eaton
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, MD, USA
| | - Roumen Vesselinov
- Department of Epidemiology and Public Health, Department of Anesthesiology, 12264University of Maryland, Baltimore, MD, USA
| | - Mentor Ahmeti
- 23506Sanford Medical Center Fargo, ND, USA.,School of Medicine and Health Sciences, 12281University of North Dakota, ND, USA
| | | | | | - Craig Sadler
- 6040Eastern Virginia Medical School, VA, USA.,Norfolk General Hospital, VA, USA
| | | | | | | | | | | | - David A Hampton
- Department of Surgery, Section of Trauma and Acute Care Surgery, University of Chicago Medicine and Biological Sciences, IL, USA
| | - Helen J Castro
- Department of Surgery, Section of Trauma and Acute Care Surgery, University of Chicago Medicine and Biological Sciences, IL, USA
| | | | | | - Lindsay O'Meara
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, MD, USA
| | - Jose J Dia
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, MD, USA
| | - Brandon R Bruns
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, MD, USA
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6
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Matevish LE, Medvecz AJ, Ebersole JM, Wanderer JP, Eastham SC, Dennis BM, Guillamondegui OD. The Silent Majority of Emergency General Surgery: An Assessment of Consult and Operative Volumes. J Surg Res 2020; 259:217-223. [PMID: 33229015 DOI: 10.1016/j.jss.2020.05.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/13/2020] [Accepted: 05/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Defining the work performed by emergency general surgery (EGS) surgeons has relied on quantifying surgical interventions, failing to include nonsurgical management performed. The purpose of this study was to identify the extent of operative and nonoperative patient management provided by an EGS service line in response to consults from other hospital providers. METHODS This is a retrospective descriptive study of all adult patients with an EGS consult request placed from July 1, 2014 to June 30, 2016 at a 1000-bed tertiary referral center. Consult requests were classified by suspected diagnosis and linked to patient demographic and clinical information. Operative and nonoperative cases were compared. RESULTS About 4998 EGS consults were requested during the 2-y period, of which 69.6% were placed on the first day of the patient encounter. Disposition outcomes after consultation included admission to the EGS service (27.6%) and discharge from the emergency department (25.3%). Small bowel obstruction, appendicitis, and cholecystitis decisively comprised the top three diagnoses for overall consults and those requiring admission to the EGS service. For every consult requiring an operation (n = 1400), 2.6 consults were managed without an operation (n = 3598). CONCLUSIONS EGS surgeons are asked to evaluate and manage a variety of potentially surgical diagnoses. As most consults do not require surgical intervention, operative volume is a poor surrogate for quantifying EGS productivity. The role of this service is vital to patient triage and disposition, particularly in the emergency department setting. Institutions should consider the volume of their nonoperative consultations when evaluating EGS service line workload and in guiding staffing needs.
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Affiliation(s)
| | - Andrew J Medvecz
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph M Ebersole
- The Brigham and Women's/Massachusetts General Hospital Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts
| | - Jonathan P Wanderer
- Department of Anesthesia and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shannon C Eastham
- Department of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley M Dennis
- Department of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oscar D Guillamondegui
- Department of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee.
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7
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Eaton B, O'Meara L, Aresco C, Scalea T, Diaz J, Bruns B. The evolution of emergency general surgery: its time for a dedicated program manager. Eur J Trauma Emerg Surg 2020; 48:5-11. [PMID: 32885311 DOI: 10.1007/s00068-020-01475-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) is emerging as a distinct sub-specialty of acute care surgery but continues to exist without essential processes that drive modern trauma programs. An EGS-specific quality program was created with service-based Advanced Practice Provider (SB APP) administrative oversight, thus validating the need for a dedicated EGS program manager. METHODS In 2017, a quality structure was formalized with primary focus on scheduled quality meetings, peer review and outcomes review. All admission, service-specific dashboards, and readmission data were manually audited by SB APPs to confirm accuracy and identify opportunities for process improvement. RESULTS Surgical quality metrics including patient volume, mortality, complications, readmission and infection prevention indicators, were reviewed by SBAPPs. Annual EMR data for all EGS patients was compared to data collected via manual review with a novel registry logic. Comparison of EMR generated data versus EGS registry data identified under-representation of total admissions: in 2016, the EMR identified 130 admissions with registry logic identifying 625 actual EGS admissions. The EMR identified 515 admissions in 2017 and 485 admission in 2018 with registry logic identifying 777 and 712, respectively. Review of readmission data revealed an error of 14 patients in 2017 and 11 patients in 2018. CONCLUSIONS The quest to improve quality of care for the EGS patient requires timely review of high-quality, accurate data by dedicated and trained personnel. Our process revealed the vital functions of an EGS PM are crucial in the evolution of the EGS specialty. LEVEL OF EVIDENCE Level IV economic and value-based evaluations.
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Affiliation(s)
- Barbara Eaton
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, 22 South Greene St, Baltimore, MD, 21201, USA.
| | - Lindsay O'Meara
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Carla Aresco
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Thomas Scalea
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, 22 South Greene St, Baltimore, MD, 21201, USA.,Department of Surgery, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Jose Diaz
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, 22 South Greene St, Baltimore, MD, 21201, USA.,Department of Surgery, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Brandon Bruns
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, 22 South Greene St, Baltimore, MD, 21201, USA.,Department of Surgery, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA
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8
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Eaton B, O'Meara L, Herrera AV, Tesoriero R, Diaz J, Bruns B. Service-Based Advanced Practice Providers: The Surgeon's Perspective. Am Surg 2020. [DOI: 10.1177/000313481908500736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The ACGME work hour restrictions facilitated increased utilization of service-based advanced practice providers (APPs) to offset reduced general surgery resident work hours. Information regarding attending surgeon perceptions of APP impact is limited. The aim of this survey was to gauge these perceptions with respect to workload, length of stay (LOS), safety, best practice, level of function, and clinical judgment. Attending surgeons on surgical teams that employ service-based APPs at an urban tertiary referral center responded to a survey at the completion of academic year 2016. Perceptions regarding APP impact on workload, LOS, safety, best practice, level of function, and clinical judgment were examined. Twenty-two attending surgeons (40%) responded. Respondents agreed that APPs always/usually decrease their workload (77%), decrease LOS (64%), improve safety (68%), contribute to best practice (82%), and decrease near misses (71%). They also agreed that APPs decrease resident workload (87%), but fewer agreed that APPs contribute to resident education (68%). The majority perceived APPs function at the PGY1/2 (43%) or PGY3 (39%) level and always/usually trust their clinical judgment (72%), and felt there was variability in level of function among APPs (56%). This single-center study illustrates that attending surgeons perceive a positive impact on patient care by service-based APPs.
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Affiliation(s)
- Barbara Eaton
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Lindsay O'Meara
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Anthony V. Herrera
- Center for Shock, Trauma and Anesthesiology Research, Baltimore, Maryland; and
| | - Ronald Tesoriero
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jose Diaz
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brandon Bruns
- Division of Acute Care Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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Keeven DD, Davenport DL, Bernard AC. Escalation of mortality and resource utilization in emergency general surgery transfer patients. J Trauma Acute Care Surg 2019; 87:43-48. [DOI: 10.1097/ta.0000000000002291] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Eaton B, Hessler L, O'Meara L, Herrera A, Tesoriero R, Diaz J, Bruns B. The impact of advanced practice providers on the surgical resident experience: Agree to disagree? Am J Surg 2018; 217:1107-1111. [PMID: 30343880 DOI: 10.1016/j.amjsurg.2018.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 10/09/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND We examined and compared APP versus surgical resident perceptions of the role of APPs in surgical subspecialty teams. METHODS Residents/first year surgical critical care fellows and inpatient service-specific APPs responded to a survey that examined perceptions about the APP-resident/fellow relationship. Statistical analysis compared responses using a Pearson chi-square test. RESULTS Thirty-two resident/fellows (48%) and 10 APPs (42%) responded. There was consensus that having an APP on service decreases workload, contributes to continuity of care and enhances resident-patient coordination education and agreement that there was clear communication and adequate collaboration. Both groups differed with respect to APPs contribution to resident/fellow clinical education, role definition and chain of command. The majority of trainees felt that APPs function at a PGY2 level (51.7%) compared to APPs, who felt that they functioned at a PGY4/5 (22%) or Fellow (44%) level. CONCLUSION APPs and resident/fellows agree that APPs impact resident workload, continuity of care and patient-coordination education.
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Affiliation(s)
- B Eaton
- University of Maryland, R Adams Cowley Shock Trauma Center, Division of Acute Care Surgery, 22 South Greene St, Baltimore MD 21201, USA.
| | - L Hessler
- Department of Surgery, University of Maryland School of Medicine, 22 South Greene St, Baltimore MD 21201, USA.
| | - L O'Meara
- University of Maryland, R Adams Cowley Shock Trauma Center, Division of Acute Care Surgery, 22 South Greene St, Baltimore MD 21201, USA.
| | - A Herrera
- Center for Shock, Trauma and Anesthesiology Research, 110 South Paca St, Room 03-002, Baltimore MD, 21201, USA.
| | - R Tesoriero
- University of Maryland, R Adams Cowley Shock Trauma Center, Division of Acute Care Surgery, 22 South Greene St, Baltimore MD 21201, USA; Department of Surgery, University of Maryland School of Medicine, 22 South Greene St, Baltimore MD 21201, USA.
| | - J Diaz
- University of Maryland, R Adams Cowley Shock Trauma Center, Division of Acute Care Surgery, 22 South Greene St, Baltimore MD 21201, USA; Department of Surgery, University of Maryland School of Medicine, 22 South Greene St, Baltimore MD 21201, USA.
| | - B Bruns
- University of Maryland, R Adams Cowley Shock Trauma Center, Division of Acute Care Surgery, 22 South Greene St, Baltimore MD 21201, USA; Department of Surgery, University of Maryland School of Medicine, 22 South Greene St, Baltimore MD 21201, USA.
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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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Greater Mortality After Emergency Laparotomy in the United Kingdom Compared With United States: A Window Into the Quality of Acute Care Surgery in the United States. Ann Surg 2017; 267:e76-e78. [PMID: 28121678 DOI: 10.1097/sla.0000000000002156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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