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Nontrauma Emergency Surgery: Optimal Case Mix for General Surgery and Acute Care Surgery Training

Cherry-Bukowiec, Jill R. MD; Miller, Barbra S. MD; Doherty, Gerard M. MD; Brunsvold, Melissa E. MD; Hemmila, Mark R. MD; Park, Pauline K. MD; Raghavendran, Krishnan MD; Sihler, Kristen C. MD; Wahl, Wendy L. MD; Wang, Stewart C. MD; Napolitano, Lena M. MD

The Journal of Trauma: Injury, Infection, and Critical Care: November 2011 - Volume 71 - Issue 5 - p 1422-1427
doi: 10.1097/TA.0b013e318232ced1
Original Article
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Background: To examine the case mix and patient characteristics and outcomes of the nontrauma emergency (NTE) service in an academic Division of Acute Care Surgery.

Methods: An NTE service (attending, chief resident, postgraduate year-3 and postgraduate year-2 residents, and two physician assistants) was created in July 2005 for all urgent and emergent inpatient and emergency department general surgery patient consults and admissions. An NTE database was created with prospective data collection of all NTE admissions initiated from November 1, 2007. Prospective data were collected by a dedicated trauma registrar and Acute Physiology and Chronic Health Evaluation-intensive care unit (ICU) coordinator daily. NTE case mix and ICU characteristics were reviewed for the 2-year time period January 1, 2008, through December 31, 2009. During the same time period, trauma operative cases and procedures were examined and compared with the NTE case mix.

Results: Thousand seven hundred eight patients were admitted to the NTE service during this time period (789 in 2008 and 910 in 2009). Surgical intervention was required in 70% of patients admitted to the NTE service. Exploratory laparotomy or laparoscopy was performed in 449 NTE patients, comprising 37% of all surgical procedures. In comparison, only 118 trauma patients (5.9% of admissions) required a major laparotomy or thoracotomy during the same time period. Acuity of illness of NTE patients was high, with a significant portion (13%) of NTE patients requiring ICU admission. NTE patients had higher admission Acute Physiology and Chronic Health Evaluation III scores [61.2 vs. 58.8 (2008); 58.2 vs. 55.8 (2009)], increased mortality [(9.71% vs. 4.89% (2008); 6.78% vs. 5.16% (2009)], and increased readmission rates (15.5% vs. 7.4%) compared with the total surgical ICU (SICU) admissions.

Conclusion: In an era of declining operative caseload in trauma, the NTE service provides ample opportunity for complex general surgery decision making and operative procedures for surgical residency education, including advanced surgical critical care management. In addition, creation of an NTE service provides an optimal general surgery case mix, including major abdominal operations, that can augment declining trauma surgery caseloads, maintain acute care faculty surgical skills, and support general and acute care surgery residency training.

From the Division of Acute Care Surgery (Trauma, Burn, Surgical Critical Care, Emergency Surgery) and Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan.

Submitted for publication May 8, 2011.

Accepted for publication August 15, 2011.

Presented at the 69th Annual Meeting of the American Association for the Surgery of Trauma, September 22–25, 2010, Boston, Massachusetts.

Address for reprints: Lena M. Napolitano, MD, Division of Acute Care Surgery, (Trauma, Burns, Critical Care, Emergency Surgery), Department of Surgery, University of Michigan, 1C340A-UH University Hospital, Box 5033, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5033; email lenan@umich.edu.

© 2011 Lippincott Williams & Wilkins, Inc.