Advertisement

A qualitative analysis of acute care surgery in the United States: It's more than just “a competent surgeon with a sharp knife and a willing attitude”

Published:December 18, 2013DOI:https://doi.org/10.1016/j.surg.2013.12.012

      Background

      Since acute care surgery (ACS) was conceptualized a decade ago, the specialty has been adopted widely; however, little is known about the structure and function of ACS teams.

      Methods

      We conducted 18 open-ended interviews with ACS leaders (representing geographic [New England, Northeast, Mid-Atlantic, South, West, Midwest] and practice [Public/Charity, Community, University] diversity). Two independent reviewers analyzed transcribed interviews using an inductive approach (NVivo qualitative analysis software).

      Results

      All respondents described ACS as a specialty treating “time-sensitive surgical disease” including trauma, emergency general surgery (EGS), and surgical critical care (SCC); 11 of 18 combined trauma and EGS into a single clinical team; 9 of 18 included elective general surgery. Emergency orthopedics, emergency neurosurgery, and surgical subspecialty triage were rare (1/18 each). Eight of 18 ACS teams had scheduled EGS operating room time. All had a core group of trauma and SCC surgeons; 13 of 18 shared EGS due to volume, human resources, or competition for revenue. Only 12 of 18 had formal signout rounds; only 2 of 18 had prospective EGS data registries. Streamlined access to EGS, evidence-based protocols, and improved education were considered strengths of ACS. ACS was described as the “last great surgical service” reinvigorated to provide “timely,” cost-effective EGS by experts in “resuscitation and critical care” and to attract “young, talented, eager surgeons” to trauma/SCC; however, there was concern that ACS might become the “wastebasket for everything that happens at inconvenient times.”

      Conclusion

      Despite rapid adoption of ACS, its implementation varies widely. Standardization of scope of practice, continuity of care, and registry development may improve EGS outcomes and allow the specialty to thrive.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Future of emergency care: hospital-based emergency care at the breaking point. Institute of Medicine, Washington, DC2006
      2. Future of emergency care: emergency medical services at the crossroads. Institute of Medicine, Washington, DC2006
        • Kim P.K.
        • Dabrowski G.P.
        • Reilly P.M.
        • Auerbach S.
        • Kauder D.R.
        • Schwab C.W.
        Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service.
        J Am Coll Surg. 2004; 199: 96-101
        • Austin M.T.
        • Diaz Jr., J.J.
        • Feurer I.D.
        • Miller R.S.
        • May A.K.
        • Guillamondegui O.D.
        • et al.
        Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital.
        J Trauma. 2005; 58: 906-910
        • Garland A.M.
        • Riskin D.J.
        • Brundage S.I.
        • Moritz F.
        • Spain D.A.
        • Purtill M.-A.
        • et al.
        A county hospital surgical practice: a model for acute care surgery.
        Am J Surg. 2007; 194: 758-764
        • Maa J.
        • Carter J.T.
        • Gosnell J.E.
        • Wachter R.
        • Harris H.W.
        The surgical hospitalist: a new model for emergency surgical care.
        J Am Coll Surg. 2007; 205: 704-711
        • Britt R.C.
        • Weireter L.J.
        • Britt L.D.
        Initial implementation of an acute care surgery model: implications for timeliness of care.
        J Am Coll Surg. 2009; 209: 421-424
        • Scherer L.A.
        • Battistella F.D.
        Trauma and emergency surgery: an evolutionary direction for trauma surgeons.
        J Trauma. 2004; 56: 7-12
        • Cherry-Bukowiec J.R.
        • Miller B.S.
        • Doherty G.M.
        • Brunsvold M.E.
        • Hemmila M.R.
        • Park P.K.
        • et al.
        Nontrauma emergency surgery: optimal case mix for general surgery and acute care surgery training.
        J Trauma. 2011; 71: 1422-1426
        • Rubinfeld I.
        • Thomas C.
        • Berry S.
        • Murthy R.
        • Obeid N.
        • Azuh O.
        • et al.
        Octogenarian abdominal surgical emergencies: not so grim a problem with the acute care surgery model?.
        J Trauma. 2009; 67: 983-989
      3. Davis R. Shortage of surgeons pinches US hospitals. USA Today. 2008 February 26.

        • Schwab C.W.
        The future of emergency care for America: in crisis, at peril and in need of resuscitation!.
        J Trauma. 2006; 61: 771-773
        • Division of Advocacy and Health Policy
        A growing crisis in patient access to emergency surgical care.
        Bull Am Coll Surg. 2006; 91: 8-19
        • O'Malley A.S.
        • Draper D.A.
        • Felland L.E.
        Hospital emergency on-call coverage: is there a doctor in the house?.
        Issue Brief Cent Stud Health Syst Change. 2007; : 1-4
      4. Accidental death and disability: The neglected disease of modern society. Institute of Medicine, Washington, DC1966
        • MacKenzie E.J.
        • Rivara F.P.
        • Jurkovich G.J.
        • Nathens A.B.
        • Frey K.P.
        • Egleston B.L.
        • et al.
        A national evaluation of the effect of trauma-center care on mortality.
        N Engl J Med. 2006; 354: 366-378
        • Celso B.
        • Tepas J.
        • Langland-Orban B.
        • Pracht E.
        • Papa L.
        • Lottenberg L.
        • et al.
        A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems.
        J Trauma. 2006; 60: 371-378
      5. Acute care surgery: trauma, critical care, and emergency surgery.
        J Trauma. 2005; 58: 614-616
        • Rotondo M.F.
        • Esposito T.J.
        • Reilly P.M.
        • Barie P.S.
        • Meredith J.W.
        • Eddy V.A.
        • et al.
        The position of the Eastern Association for the Surgery of Trauma on the future of trauma surgery.
        J Trauma. 2005; 59: 77-79
        • Ball C.G.
        • Hameed S.M.
        • Brenneman F.D.
        Acute care surgery: a new strategy for the general surgery patients left behind.
        Can J Surg. 2010; 53: 84-85
        • Ciesla D.J.
        • Moore E.E.
        • Moore J.B.
        • Johnson J.L.
        • Cothren C.C.
        • Burch J.M.
        The academic trauma center is a model for the future trauma and acute care surgeon.
        J Trauma. 2005; 58: 657-661
        • Yaghoubian A.
        • Kaji A.H.
        • Ishaque B.
        • Park J.
        • Rosing D.K.
        • Lee S.
        • et al.
        Acute care surgery performed by sleep deprived residents: are outcomes affected?.
        J Surg Res. 2010; 163: 192-196
        • Pryor J.P.
        • Reilly P.M.
        • Schwab C.W.
        • Kauder D.R.
        • Dabrowski G.P.
        • Gracias V.H.
        • et al.
        Integrating emergency general surgery with a trauma service: impact on the care of injured patients.
        J Trauma. 2004; 57: 467-471
        • Earley A.S.
        • Pryor J.P.
        • Kim P.K.
        • Hedrick J.H.
        • Kurichi J.E.
        • Minogue A.C.
        • et al.
        An acute care surgery model improves outcomes in patients with appendicitis.
        Ann Surg. 2006; 244: 498-504
        • Ekeh A.P.
        • Monson B.
        • Wozniak C.J.
        • Armstrong M.
        • McCarthy M.C.
        Management of acute appendicitis by an acute care surgery service: is operative intervention timely?.
        J Am Coll Surg. 2008; 207: 43-48
        • Lehane C.W.
        • Jootun R.N.
        • Bennett M.
        • Wong S.
        • Truskett P.
        Does an acute care surgical model improve the management and outcome of acute cholecystitis?.
        ANZ J Surg. 2010; 80: 438-442
        • Lau B.
        • Difronzo L.A.
        An acute care surgery model improves timeliness of care and reduces hospital stay for patients with acute cholecystitis.
        Am Surg. 2011; 77: 1318-1321
        • Stawicki S.P.
        • Brooks A.
        • Bilski T.
        • Scaff D.
        • Gupta R.
        • Schwab C.W.
        • et al.
        The concept of damage control: extending the paradigm to emergency general surgery.
        Injury. 2008; 39: 93-101
        • Ciesla D.J.
        • Cha J.Y.
        • Smith 3rd, J.S.
        • Llerena L.E.
        • Smith D.J.
        Implementation of an acute care surgery service at an academic trauma center.
        Am J Surg. 2011; 202: 779-785
        • Qureshi A.
        • Smith A.
        • Wright F.
        • Brenneman F.
        • Rizoli S.
        • Hsieh T.
        • et al.
        The impact of an acute care emergency surgical service on timely surgical decision-making and emergency department overcrowding.
        J Am Coll Surg. 2011; 213: 284-293
        • Santry H.P.
        • Janjua S.
        • Chang Y.
        • Petrovick L.
        • Velmahos G.C.
        Interhospital transfers of acute care surgery patients: a plea for regionalization of care.
        World J Surg. 2011; 35: 2660-2667
        • Britt R.C.
        • Bouchard C.
        • Weireter L.J.
        • Britt L.D.
        Impact of acute care surgery on biliary disease.
        J Am Coll Surg. 2010; 210: 595-599
        • Matsushima K.
        • Cook A.
        • Tollack L.
        • Shafi S.
        • Frankel H.
        An acute care surgery model provides safe and timely care for both trauma and emergency general surgery patients.
        J Surg Res. 2011; 166: e143-e147
        • Malterud K.
        Qualitative research: standards, challenges, and guidelines.
        Lancet. 2001; 358: 483-488
        • Giacomini M.K.
        • Cook D.J.
        Users' guides to the medical literature: XXIII. Qualitative research in health care B. What are the results and how do they help me care for my patients? Evidence-Based Medicine Working Group.
        JAMA. 2000; 284: 478-482
        • Giacomini M.K.
        • Cook D.J.
        Users' guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence-Based Medicine Working Group.
        JAMA. 2000; 284: 357-362
        • Bradley E.H.
        • Curry L.A.
        • Devers K.J.
        Qualitative data analysis for health services research: developing taxonomy, themes, and theory.
        Health Serv Res. 2007; 42: 1758-1772
        • Glaser B.G.
        • Strauss A.L.
        The discovery of grounded theory: strategies for qualitative research.
        Aldine Publishing Company, Chicago1967
        • Jurkovich G.J.
        Acute care surgery: The trauma surgeon's perspective.
        Surgery. 2007; 141: 293-296
        • Reilly P.M.
        • Schwab C.W.
        Acute care surgery: the academic hospital's perspective.
        Surgery. 2007; 141: 299-301
        • Rotondo M.F.
        At the center of the “perfect storm”: the patient.
        Surgery. 2007; 141: 291-292
        • Gandy R.C.
        • Truskett P.G.
        • Wong S.W.
        • Smith S.
        • Bennett M.H.
        • Parasyn A.D.
        Outcomes of appendicectomy in an acute care surgery model.
        Med J Aust. 2010; 193: 281-284
        • Cubas R.F.
        • Gomez N.R.
        • Rodriguez S.
        • Wanis M.
        • Sivanandam A.
        • Garberoglio C.A.
        Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: impact on timing and cost.
        J Am Coll Surg. 2012; 215: 715-721
        • Philibert I.
        Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications.
        Qual Saf Health Care. 2009; 18: 261-266
        • Zendejas B.
        • Ali S.M.
        • Huebner M.
        • Farley D.R.
        Handing over patient care: is it just the old broken telephone game?.
        J Surg Educ. 2011; 68: 465-471
        • Arora V.M.
        • Manjarrez E.
        • Dressler D.D.
        • Basaviah P.
        • Halasyamani L.
        • Kripalani S.
        Hospitalist handoffs: a systematic review and task force recommendations.
        J Hosp Med. 2009; 4: 433-440
        • Riesenberg L.A.
        • Leitzsch J.
        • Massucci J.L.
        • Jaeger J.
        • Rosenfeld J.C.
        • Patow C.
        • et al.
        Residents' and attending physicians' handoffs: a systematic review of the literature.
        Acad Med. 2009; 84: 1775-1787
        • Telem D.A.
        • Buch K.E.
        • Ellis S.
        • Coakley B.
        • Divino C.M.
        Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.
        Arch Surg. 2011; 146: 89-93
        • Sanfey H.
        • Stiles B.
        • Hedrick T.
        • Sawyer R.G.
        Morning report: combining education with patient handover.
        Surgeon. 2008; 6: 94-100
        • Stiles B.M.
        • Reece T.B.
        • Hedrick T.L.
        • Garwood R.A.
        • Hughes M.G.
        • Dubose J.J.
        • et al.
        General surgery morning report: a competency-based conference that enhances patient care and resident education.
        Curr Surg. 2006; 63: 385-390
        • Emlet L.L.
        • Al-Khafaji A.
        • Kim Y.H.
        • Venkataraman R.
        • Rogers P.L.
        • Angus D.C.
        Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units.
        Crit Care Med. 2012; 40: 3129-3134
        • Selden N.R.
        American College of Surgeons trauma center verification requirements.
        J Am Coll Surg. 2013; 216: 167
        • Becher R.D.
        • Meredith J.W.
        • Chang M.C.
        • Hoth J.J.
        • Beard H.R.
        • Miller P.R.
        Creation and implementation of an emergency general surgery registry modeled after the National Trauma Data Bank.
        J Am Coll Surg. 2012; 214: 156-163
        • Gunter O.L.
        • Guillamondegui O.D.
        • May A.K.
        • Diaz J.J.
        Outcome of necrotizing skin and soft tissue infections.
        Surg Infect (Larchmt). 2008; 9: 443-450
        • Williams Jr., T.E.
        • Ellison E.C.
        Population analysis predicts a future critical shortage of general surgeons.
        Surgery. 2008; 144: 548-554
        • Fischer J.E.
        The impending disappearance of the general surgeon.
        JAMA. 2007; 298: 2191-2193
        • Polk Jr., H.C.
        • Bland K.I.
        • Ellison E.C.
        • Grosfeld J.
        • Trunkey D.D.
        • Stain S.C.
        • et al.
        A proposal for enhancing the general surgical workforce and access to surgical care.
        Ann Surg. 2012; 255: 611-617
        • Sheldon G.F.
        Access to care and the surgeon shortage: American Surgical Association forum.
        Ann Surg. 2010; 252: 582-590
        • Stitzenberg K.B.
        • Sheldon G.F.
        Progressive specialization within general surgery: adding to the complexity of workforce planning.
        J Am Coll Surg. 2005; 201: 925-932
        • Liu J.H.
        • Etzioni D.A.
        • O'Connell J.B.
        • Maggard M.A.
        • Ko C.Y.
        The increasing workload of general surgery.
        Arch Surg. 2004; 139: 423-428
        • Etzioni D.A.
        • Liu J.H.
        • Maggard M.A.
        • Ko C.Y.
        The aging population and its impact on the surgery workforce.
        Ann Surg. 2003; 238: 170-177