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Spain DA, Cryer HG. The acute care surgery model and elective surgery. J Trauma Acute Care Surg 2023; 95:e42-e44. [PMID: 37335180 DOI: 10.1097/ta.0000000000004089] [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: 06/21/2023]
Abstract
ABSTRACT Two senior surgeons with active elective surgery practices call on their personal experiences to encourage acute care surgery programs to explore ways to incorporate elective surgery into their practice models. Although there are obstacles, these are not insurmountable problems, potential solutions exist, and this may help protect against burnout.
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Affiliation(s)
- David A Spain
- From the David L. Gregg, MD, Professor/Chief of Acute Care Surgery, Department of Surgery, Stanford University (D.A.S.), Stanford; and Department of Surgery (H.G.C.), UCLA, Los Angeles, California
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2
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Janczewski LM, Tatebe LC. Racial Inequities in Emergency Surgery Consultation in Medicare Patients. JAMA Surg 2022; 157:1104. [PMID: 36223134 DOI: 10.1001/jamasurg.2022.4965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
| | - Leah C Tatebe
- Department of Surgery, Northwestern University, Chicago, Illinois
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3
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Schena CA, de’Angelis GL, Carra MC, Bianchi G, de’Angelis N. Antimicrobial Challenge in Acute Care Surgery. Antibiotics (Basel) 2022; 11:antibiotics11101315. [PMID: 36289973 PMCID: PMC9598495 DOI: 10.3390/antibiotics11101315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/07/2022] Open
Abstract
The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients’ morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.
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Affiliation(s)
- Carlo Alberto Schena
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Gian Luigi de’Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
- Correspondence:
| | - Maria Clotilde Carra
- Rothschild Hospital, AP-HP, Université Paris Cité, U.F.R. of Odontology, 75006 Paris, France
| | - Giorgio Bianchi
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Nicola de’Angelis
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
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Cairns AL, Hess AB, Rieken H, Lin N, Rao S, Jee Y, Ashburn JH, Miller PR, Carmichael SP, Mowery NT. Equivalent Operative Outcomes for Emergency Colon Cancer Resections Among Acute Care Surgeons and Specialists in Colorectal Surgery. Am Surg 2022; 88:959-963. [PMID: 35199571 DOI: 10.1177/00031348211050820] [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: 11/15/2022]
Abstract
OBJECTIVES Improved screening has decreased but not eliminated the need for emergent surgery for colon cancer (CC), many of which are performed by acute care surgery (ACS) surgeons. This retrospective review compares outcomes for CC resections on the ACS service to the surgical oncology and colorectal services (SO/CRS). METHODS Retrospective review was performed for CC operations between 2014 and 2019. Data for margin status, cancer stage, number of lymph nodes dissected, time to medical oncology follow-up, and time to initiation of chemotherapy were collected. Patients with curative resection, who chose comfort care, presented on alternative services or with non-CC indications as well as those were lost to follow-up were excluded. RESULTS 36 ACS patients and 269 SO/CRS patients underwent CC resections. Most ACS patients presented emergently compared to the SO/CC group (83.3% vs 1%, P < .05) as well as with more advanced tumor stage. There were no statistically significant differences for presence of metastatic disease, number of lymph nodes obtained, or time to post-surgical care (in days) and chemotherapy initiation (in days). 3 (8%) EGS patients had positive margins compared to 6 (2%) CRS/SO patients due to the presence of perforated tumors in the ACS group (p < .05). There were no statistically significant differences in 30- day or 1-year mortality despite the emergent presentation of the ACS patients. DISCUSSION These findings suggest that despite emergent presentation and advanced disease burden, ACS surgeons provide quality care to CC patients, both in the operating room and in coordination of care.
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Affiliation(s)
- Ashley L Cairns
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Alexis B Hess
- 12325The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Holly Rieken
- 19902Wright Patterson Air Force Base, Wright Patterson AFB, OH, USA
| | - Nicholas Lin
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Shambavi Rao
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Yoonsun Jee
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Jean H Ashburn
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Preston R Miller
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | | | - Nathan T Mowery
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
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Work Characteristics of Acute Care Surgeons at a Swiss Tertiary Care Hospital: A Prospective One-Month Snapshot Study. World J Surg 2021; 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] [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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Kinnear N, Jolly S, Herath M, Han J, Tran M, O'Callaghan M, Hennessey D, Dobbins C, Sammour T, Moore J. The acute surgical unit: An updated systematic review and meta-analysis. Int J Surg 2021; 94:106109. [PMID: 34536599 DOI: 10.1016/j.ijsu.2021.106109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/07/2021] [Accepted: 09/07/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To systematically review comparative studies on the acute surgical unit (ASU) model. METHODS Searches were performed of Cochrane, Embase, Medline and grey literature. Eligible articles were comparative studies of the Acute Surgical Unit (ASU) model published 01/01/2000-12/03/2020. Amongst patients with any diagnosis, primary outcomes were length of stay, after-hours operating, complications and cost. Secondary outcomes were time to surgical review, time to theatre, mortality and re-admission for patients with any diagnosis, and cholecystectomy during index admission for patients with biliary disease. Additional analyses were planned for specific cohorts, such as patients with appendicitis or cholecystitis. RESULTS Searches returned 9,677 results from which 77 eligible publications were identified, representing 150,981 unique patients. Cohorts were adequately homogenous for meta-analysis of all outcomes except cost. For patients with any diagnosis, compared with the Traditional model, the introduction of an ASU model was associated with reduced length of stay (mean difference [MD] 0.68 days; 95% confidence interval [CI] 0.38-0.98), after-hours operating rates (odds ratio [OR] 0.56; 95% CI 0.46-0.69) and complications (OR 0.48, 95% CI 0.33-0.70). Regarding cost, two studies reported savings following ASU introduction, while one found no difference. Amongst secondary outcomes, for patients with any diagnosis, ASU commencement was associated with reduced time to surgical review, time to theatre and mortality. Re-admissions were unchanged. For patients with biliary disease, ASU establishment was associated with superior rates of index cholecystectomy. CONCLUSION Compared to the Traditional structure, the ASU model is superior for most metrics. ASU introduction should be promoted in policy for widespread benefit.
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Affiliation(s)
- Ned Kinnear
- Adelaide Medical School, University of Adelaide, Adelaide, Australia Dept of Surgery, Royal Adelaide, Hospital, Adelaide, Australia Urology Unit, Flinders Medical Centre, Bedford Park, SA, Australia Flinders University, Adelaide, Australia Dept of Urology, Mercy University Hospital, Cork, Ireland
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Bugaev N, Hojman HM, Breeze JL, Nasraway SA, Arabian SS, Holewinski S, Johnson BP. Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic. Am Surg 2020; 86:1629-1635. [PMID: 33231486 PMCID: PMC7688435 DOI: 10.1177/0003134820972084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of an acute care surgery (ACS) service during the COVID-19 pandemic is not well established. METHODS A retrospective review of the ACS service performance in an urban tertiary academic medical center. The study was performed between January and May 2020. The demographics, clinical characteristics, and outcomes of patients treated by the ACS service 2 months prior to the COVID surge (pre-COVID group) and during the first 2 months of the COVID-19 pandemic (surge group) were compared. RESULTS Trauma and emergency general surgery volumes decreased during the surge by 38% and 57%, respectively; but there was a 64% increase in critically ill patients. The proportion of patients in the Department of Surgery treated by the ACS service increased from 40% pre-COVID to 67% during the surge. The ACS service performed 32% and 57% of all surgical cases in the Department of Surgery during the pre-COVID and surge periods, respectively. The ACS service managed 23% of all critically ill patients in the institution during the surge. Critically ill patients with and without confirmed COVID-19 infection treated by ACS and non-ACS intensive care units during the surge did not differ in demographics, indicators of clinical severity, or hospital mortality:13.4% vs. 13.5% (P = .99) for all critically ill patients; and 13.9% vs. 27.4% (P = .12) for COVID-19 critically ill patients. CONCLUSION Acute care surgery is an "essential" service during the COVID-19 pandemic, capable of managing critically ill nonsurgical patients while maintaining the provision of trauma and emergent surgical services. LEVEL OF EVIDENCE III. STUDY TYPE Therapeutic.
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Affiliation(s)
- Nikolay Bugaev
- Division of Trauma & Acute Care
Surgery, Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Horacio M. Hojman
- Division of Trauma & Acute Care
Surgery, Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Janis L. Breeze
- Tufts Clinical and Translational Science
Institute, Tufts University, and Institute for Clinical Research and
Health Policy Studies, Tufts Medical
Center, Boston, MA, USA
| | - Stanley A. Nasraway
- Department of Surgery,
Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Sandra S. Arabian
- Division of Trauma & Acute Care
Surgery, Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Sharon Holewinski
- Department of Surgery,
Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Benjamin P. Johnson
- Division of Trauma & Acute Care
Surgery, Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
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Meschino MT, Giles AE, Rice TJ, Saddik M, Doumouras AG, Nenshi R, Allen L, Vogt K, Engels PT. Operative timing is associated with increased morbidity and mortality in patients undergoing emergency general surgery: a multisite study of emergency general services in a single academic network. Can J Surg 2020; 63:E321-E328. [PMID: 32644317 DOI: 10.1503/cjs.012919] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background Despite the widespread implementation of the acute care surgery (ACS) model, limited access to operating room time represents a barrier to the optimal delivery of emergency general surgery (EGS) care. The objective of this study was to describe the effect of operative timing on outcomes in EGS in a network of teaching hospitals. Methods We conducted a retrospective review of EGS operations performed at 3 teaching hospitals in a single academic network. Time of operation was categorized as daytime (8 am to 5 pm), after hours (5 pm to 11 pm) or overnight (11 pm to 8 am). Time to operation was calculated as the interval from admission to operative start time and categorized as less than 24 hours, 24-72 hours and greater than 72 hours. Results After we excluded nonindex cases, trauma cases and cases occurring more than 5 days after admission, 1505 EGS cases were included. We found that 39.0% of operations were performed in the daytime, 46.3% after hours and 14.8% overnight. In terms of time to operation, 52.3% of operations were performed within 24 hours of admission, 33.4% in 24-72 hours and 14.3% in more than 72 hours. The overall complication rate was 20.6% (310 patients) and the overall mortality rate was 3.8% (57 patients). After multivariable analysis, time to operation more than 72 hours after admission was independently associated with increased odds of morbidity (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.09-2.47), while overnight operating was associated with increased odds of death (OR 3.15, 95% CI 1.29-7.70). Conclusion Increasing time from admission to operation and overnight operating were associated with greater morbidity and mortality, respectively, for EGS patients. Strategies to provide timely access to the operating room should be considered to optimize care in an ACS model.
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Affiliation(s)
- Michael T Meschino
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Meschino, Giles, Rice, Saddik, Doumouras, Nenshi, Engels); and the Department of Surgery, Western University, London, Ont. (Allen, Vogt)
| | - Andrew E Giles
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Meschino, Giles, Rice, Saddik, Doumouras, Nenshi, Engels); and the Department of Surgery, Western University, London, Ont. (Allen, Vogt)
| | - Timothy J Rice
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Meschino, Giles, Rice, Saddik, Doumouras, Nenshi, Engels); and the Department of Surgery, Western University, London, Ont. (Allen, Vogt)
| | - Maisa Saddik
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Meschino, Giles, Rice, Saddik, Doumouras, Nenshi, Engels); and the Department of Surgery, Western University, London, Ont. (Allen, Vogt)
| | - Aristithes G Doumouras
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Meschino, Giles, Rice, Saddik, Doumouras, Nenshi, Engels); and the Department of Surgery, Western University, London, Ont. (Allen, Vogt)
| | - Rahima Nenshi
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Meschino, Giles, Rice, Saddik, Doumouras, Nenshi, Engels); and the Department of Surgery, Western University, London, Ont. (Allen, Vogt)
| | - Laura Allen
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Meschino, Giles, Rice, Saddik, Doumouras, Nenshi, Engels); and the Department of Surgery, Western University, London, Ont. (Allen, Vogt)
| | - Kelly Vogt
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Meschino, Giles, Rice, Saddik, Doumouras, Nenshi, Engels); and the Department of Surgery, Western University, London, Ont. (Allen, Vogt)
| | - Paul T Engels
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Meschino, Giles, Rice, Saddik, Doumouras, Nenshi, Engels); and the Department of Surgery, Western University, London, Ont. (Allen, Vogt)
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Hardy K, Metcalfe J, Clouston K, Vergis A. The Impact of an Acute Care Surgical Service on the Quality and Efficiency of Care Outcome Indicators for Patients with General Surgical Emergencies. Cureus 2019; 11:e5036. [PMID: 31501728 PMCID: PMC6721875 DOI: 10.7759/cureus.5036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Acute care surgery (ACS) models address high volumes of emergency general surgery and emergency room (ER) overcrowding. The impact of ACS service model implementation on the quality and efficiency of care (EOC) outcomes in acute appendicitis (AA) and acute cholecystitis (AC) cohorts was evaluated. Methods A retrospective chart review (N=1,229) of adult AA and AC patients admitted prior to (pre-ACS; n=507; three hospitals; 2007) and after regionalization (R-ACS; n=722; one hospital; 2011). Results R-ACS time to ER physician assessment was significantly longer for AA (3.4 ± 2.3 versus 2.4 ± 2.6 hr; p ≤ 0.001). Surgical response times (1.3 ± 1.2 vs 2.6 ± 4.3 hr for AA; 1.8 ± 1.5 vs 4.1 ± 5.0 hr for AC; p ≤ 0.0001) and acquisition of imaging (4.1 ± 4.1 vs 6.9 ± 9.9 hr for AA, p ≤ 0.0001; 7.8 ± 1.9 vs 13.2 ± 18.5 hr for AC, p ≤ 0.008) occurred significantly faster with R-ACS. R-ACS resulted in a significant increase in night-time appendectomies (21.7% vs 11.1%; p ≤ 0.002), perforated appendices (29.1 % vs 18.9 %; p ≤ 0.006), 30-day readmissions (4.56% vs 0.82%; p ≤ 0.01), and lower rate of intraoperative complications for AC patients (2.78% vs 7.69%; p ≤ 0.02). Conclusions Despite the increased volume of patients seen with the implementation of R-ACS, surgical assessments and diagnostic imaging were significantly more prompt. EOC measures were maintained. Worse AA outcomes highlight areas for improvement in delivering R-ACS.
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Affiliation(s)
- Krista Hardy
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
| | - Jennifer Metcalfe
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
| | - Kathleen Clouston
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
| | - Ashley Vergis
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
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