Vascular surgical emergencies: how will future surgeons be trained?

Defining the burden, scope, and future of vascular acute care surgery

OBJECTIVE

The paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surgical procedures in Maryland.

METHODS

A retrospective analysis of a statewide inpatient database was performed to identify patients undergoing noncardiac vascular procedures in Maryland from 2009 to 2013. Patients were stratified by admission acuity as elective, urgent, or emergent, with the last two groups defined as acute. The primary outcome was inpatient mortality, and secondary outcomes were critical care and hospital resource requirements. Groups were compared by univariate analyses, with multivariable analysis of mortality based on acuity level and other potential risk factors for death.

RESULTS

Of 3,157,499 adult hospital admissions, 154,004 (5%) patients underwent a vascular procedure; most were acute (54% emergent, 13% urgent), whereas 33% were elective. Acute patients had higher rates of critical care morbidity and required more hospital resource utilization. Admission for acute vascular surgery was independently associated with mortality (urgent odds ratio, 2.1; emergent odds ratio, 3.0).

CONCLUSIONS

The majority of inpatient vascular care in Maryland is for acute vascular surgery, which is an independent risk factor for mortality. Acute vascular surgical care entails greater critical care and hospital resource utilization and-similar to emergency general surgery-may benefit from dedicated training and practice models.

The influence of key clinical practices on the knowledge of first year doctors about the patients under their care

AIMS

In 2009 in the United Kingdom the 48-h working week was introduced for junior doctors. To comply with this traditional working practices have changed. This study aims to assess how much first year (FY1) doctors know about the acute surgical patients they manage and how this is influenced by changes in key working practices.

METHODS

Surgical FY1s working in NHS hospitals answered 16 clinical questions about a standard acute surgical patient under their care 48 h after admission. Scores were analysed according to how long the FY1 had been looking after the patient, whether they had clerked the patient in, attended the post take ward round (PTWR), used a handover sheet to answer the questions and had sole or shared responsibility for the patient.

RESULTS

Two hundred and seventy-four FY1s (92% response rate) from 36 hospitals were surveyed. The overall median score was 11/16 (inter-quartile range 8-13). Only 8.4% (23/274) FY1s had clerked in the patient and 58.4% (160/274) had attended the PTWR. Clerking patients and attending the PTWR resulted in significantly higher test scores compared to FY1s who did not perform these activities (p = < 0.001 and 0.001 respectively). The scores of the 67.2% who used a handover sheet were significantly lower than those who did not (p = 0.001). Having sole or shared responsibility and duration of care made no significant difference (p = 0.143 and p = 0.458 respectively)

CONCLUSIONS

The results demonstrate that junior doctors' knowledge of their patients is significantly enhanced when they have the opportunity to perform the admission clerking and attend the PTWR. Because of working hours' restrictions this is now rare. Although use of handover sheets appears to ensure that certain key facts immediately related to the current admission are passed on, it is associated with significantly poorer wider knowledge of the patient.

Vascular surgery within general surgery: an analysis of workload 1989-2005

INTRODUCTION

There is considerable debate as to whether vascular surgery should be a subspecialty separate from general surgery. This study examines the changing relationship between general and vascular surgery in a district general surgical unit over 16 years.

PATIENTS AND METHODS

A detailed survey of referrals, admissions and operations to one unit was carried out over 3 months in 2003. This was compared with similar surveys in 1989, 1990 and 1995. In addition a 3-month audit of operations performed was carried out in 2005 following a decision by the Primary Care Trust (PCT) to reduce varicose vein referrals.

RESULTS

There was a significant increase in the number of varicose vein and arterial referrals 1989-2003 (P = 0.0001 and P < 0.0001, respectively). This was reflected in increased number of vascular admissions (P < 0.0001). In 1989, 14% of the arterial cases were admitted as emergencies. This figure rose to 52% in 2003 (P < 0.0001). There was a significant increase in the number of arterial operations performed between 1989 and 1995; however, from 1995 to 2003 this number fell P < 0.0001). The number of varicose vein procedures increased significantly 1989-2003 (P < 0.0001), with a significant fall after the PCT decision (P < 0.0001). However, the number of operations carried out in 2005 increased slightly with the proportion of general surgical cases, mostly hernia repairs and laparoscopic cholecystectomies, increasing.

CONCLUSIONS

With increasing specialisation comes the risk that reduction in any aspect of a particular specialty may result in that unit becoming unsustainable. In vascular surgery this will inevitably lead to centralisation of services. In a large district general hospital having two general surgeons with a vascular interest, the general surgical component has maintained the workload of the unit following reduction in varicose vein referrals.