Retrospective analysis of small intracranial hemorrhage in trauma: Is acute care surgery team management alone safe?

Background: The Brain Injury Guidelines (BIG) provide a validated framework for categorizing patients with small intracranial haemorrhages (ICH) who could be managed by acute care surgery without neurosurgical consultation or repeat head computed tomography in the absence of neurological deterioration. This replication study retrospectively applied BIG criteria to ICH subjects and only included BIG1 and BIG2 subjects.Methods: The trauma registry was queried from 2014 to 2019 for subjects with a traumatic ICH <1 cm, Glasgow Coma Scale score of 14/15 and not on anticoagulation therapy. Patients were then categorized under BIG 1 or BIG2 and outcomes were evaluated.Results: Two hundred fourteen subjects were reviewed (88 BIG1 and 126 BIG2). Twenty-three subjects had worse repeat imaging, but only one had worsening exam that resolved spontaneously. None required neurosurgical intervention. One died of non-neurological causes.Conclusions: Retrospective analysis supported our hypothesis that patients categorized as BIG1 or BIG2 could have been safely managed by acute care surgeons without neurosurgical consultation or repeat head imaging. A review of minor worsening on repeat imaging without changes in neurological exams and no need for neurosurgical interventions supports this evidence-based approach to the management of small intracranial haemorrhages.

Pro-con debate on regionalization of emergency general surgery: controversy or common sense?

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.

Geographic Diffusion and Implementation of Acute Care Surgery: An Uneven Solution to the National Emergency General Surgery Crisis

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.

Creating a Global Acute Care Surgery Fellowship to Meet International Need

INTRODUCTION

Existing Acute Care Surgery (ACS) fellowships are positioned to develop well-trained surgeons with specific skills to facilitate improvements in care delivery in Global ACS. Many resident and fellowship programs offer clinical electives that expose trainees to operative experiences, exposing trainees to the needs in resource-challenged settings. However, most lack a focus on long-term development and research designed to enhance the country's local skills, capability, and capacity. The Global Acute Care Surgery (Global ACS) fellowship produces a surgeon who focuses on capacity building and systems development across the world.

METHODS

At Vanderbilt University, the current American Association for the Surgery of Trauma-Acute Care Surgery (AAST-ACS) fellowship was adapted to create an academic Global Acute Care Surgery (Global ACS) fellowship. This fellowship specifically enhances fellowship trainee's skills in needs assessment and performing research to facilitate the development and implementation of trauma and acute care surgery systems in low- and middle income countries. This research will foster context-appropriate data, collected and based in low- and middle-income countries, to guide practice and policy.

RESULTS AND CONCLUSION

Two fellows have completed the Global ACS fellowship at Vanderbilt University. The fellowship requirements, clinical skills, project development and overall goals are outlined within the article. Challenges, funding, and mentorship must also be addressed to develop a comprehensive fellowship. A sample two-year timeline is provided to complete the fellowship track and meet the defined goals. A structured global acute care surgery fellowship enables fellows to reduce the surgical burden of disease and contribute to surgical systems development at both local and international levels by creating meaningful research and developing sustainable change in LMIC countries.

Impact of acute care surgery to departmental productivity

BACKGROUND

The face of trauma surgery is rapidly evolving with a paradigm shift toward acute care surgery (ACS). The formal development of ACS has been viewed by some general surgeons as a threat to their practice. We sought to evaluate the impact of a new division of ACS to both departmental productivity and provider satisfaction at a University Level I Trauma Center.

METHODS

Two-year retrospective analysis of annual work relative value unit (wRVU) productivity, operative volume, and FTEs before and after establishment of an ACS division at a University Level I trauma center. Provider satisfaction was measured using a 10-point scale. Analysis completed using Microsoft Excel with a p value less than 0.05 significant.

RESULTS

The change to an ACS model resulted in a 94% increase in total wRVU production (78% evaluation and management, 122% operative; p<0.05) for ACS, whereas general surgery wRVU production increased 8% (-15% evaluation and management, 14% operative; p<0.05). Operative productivity was substantial after transition to ACS, with 129% and 44% increases (p<0.05) in operative and elective case load, respectively. Decline in overall general surgery operative volume was attributed to reduction in emergent cases. Establishment of the ACS model necessitated one additional FTE. Job satisfaction substantially improved with the ACS model while allowing general surgery a more focused practice.

CONCLUSIONS

The ACS practice model significantly enhances provider productivity and job satisfaction when compared with trauma alone. Fears of a productivity impact to the nontrauma general surgeon were not realized.