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Variations in the implementation of acute care surgery: Results from a national survey of university-affiliated hospitals

Santry, Heena P. MD, MS; Madore, John C.; Collins, Courtney E. MD; Ayturk, M. Didem MS; Velmahos, George C. MD, PhD, MSEd; Britt, L.D. MD, MPH; Kiefe, Catarina I. PhD, MD

Journal of Trauma and Acute Care Surgery: January 2015 - Volume 78 - Issue 1 - p 60–68
doi: 10.1097/TA.0000000000000492
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BACKGROUND To date, no studies have reported nationwide adoption of acute care surgery (ACS) or identified structural and/or process variations for the care of emergency general surgery (EGS) patients within such models.

METHODS We surveyed surgeons responsible for EGS coverage at University Health Systems Consortium hospitals using an eight-page postal/e-mail questionnaire querying respondents on hospital and EGS structure/process measures. Survey responses were analyzed using descriptive statistics, univariate comparisons, and multivariable regression models.

RESULTS Of 319 potential respondents, 258 (81%) completed the surveys. A total of 81 hospitals (31%) had implemented ACS, while 134 (52%) had a traditional general surgeon on-call (GSOC) model. Thirty-eight hospitals (15%) had another model (hybrid). Larger-bed, university-based, teaching hospitals with Level 1 trauma center verification status located in urban areas were more likely to have adopted ACS. In multivariable modeling, hospital type, setting, and trauma center verification predicted ACS implementation. EGS processes of care varied, with 28% of the GSOC hospitals having block time versus 67% of the ACS hospitals (p < 0.0001), 45% of the GSOC hospitals providing ICU [intensive care unit] care to EGS patients in a surgical/trauma ICU versus 93% of the ACS hospitals (p < 0.0001), 5.7 ± 3.2 surgeons sharing call at GSOC hospitals versus 7.9 ± 2.3 surgeons at ACS hospitals (p < 0.0001), and 13% of the GSOC hospitals requiring in-house EGS call versus 75% of the ACS hospitals (p < 0.0001). Among ACS hospitals, there were variations in patient cohorting (EGS patients alone, 25%; EGS + trauma, 21%; EGS + elective, 17%; and EGS + trauma + elective, 30%), data collection (26% had prospective EGS registries), patient hand-offs (56% had attending surgeon presence), and call responsibilities (averaging 4.8 ± 1.3 calls per month, with 60% providing extra call stipend and 40% with no postcall clinical duties).

CONCLUSION The potential of the ACS on the national crisis in access to EGS care is not fully met. Variations in EGS processes of care among adopters of ACS suggest that standardized criteria for ACS implementation, much like trauma center verification criteria, may be beneficial.

Supplemental digital content is available in the article.

From the Departments of Surgery (H.P.S., J.C.M., C.E.C., M.D.A.), and Quantitative Health Sciences (H.P.S., C.I.K.), University of Massachusetts Medical School, Worcester; and Department of Surgery (G.C.V.), Massachusetts General Hospital, Boston, Massachusetts; and Department of Surgery (L.D.B.), Eastern Virginia Medical School, Norfolk, Virginia.

Submitted: August 21, 2014, Revised: September 19, 2014, Accepted: October 2, 2014.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Address for reprints: Heena P. Santry, MD, Department of Surgery, Room S3-731, 55 Lake Avenue North, Worcester, MA 01655; email: Heena.Santry@umassmemorial.org.

© 2015 Lippincott Williams & Wilkins, Inc.