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Vadlakonda A, Cho NY, Tran Z, Curry J, Sakowitz S, Balian J, Coaston T, Tillou A, Benharash P. Demystifying the association of center-level operative trauma volume and outcomes of emergency general surgery. Surgery 2024:S0039-6060(24)00210-1. [PMID: 38760230 DOI: 10.1016/j.surg.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/16/2024] [Accepted: 03/21/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Recent studies have demonstrated a positive volume-outcome relationship in emergency general surgery. Some have advocated for the sub-specialization of emergency general surgery independent from trauma. We hypothesized inferior clinical outcomes of emergency general surgery with increasing center-level operative trauma volume, potentially attributable to overall hospital quality. METHODS Adults (≥18 years) undergoing complex emergency general surgery operations (large and small bowel resection, repair of perforated peptic ulcer, lysis of adhesions, laparotomy) were identified in the 2016 to 2020 Nationwide Readmissions Database. Multivariable risk-adjusted models were developed to evaluate the association of treatment at a high-volume trauma center (reference: low-volume trauma center) with clinical and financial outcomes after emergency general surgery. To evaluate hospital quality, mortality among adult hospitalizations for acute myocardial infarction was assessed by hospital trauma volume. RESULTS Of an estimated 785,793 patients undergoing a complex emergency general surgery operation, 223,116 (28.4%) were treated at a high-volume trauma center. Treatment at a high-volume trauma center was linked to 1.19 odds of in-hospital mortality (95% confidence interval 1.12-1.27). Although emergency general surgery volume was associated with decreasing predicted risk of mortality, increasing trauma volume was linked to an incremental rise in the odds of mortality after emergency general surgery. Secondary analysis revealed increased mortality for admissions for acute myocardial infarction with greater trauma volume. CONCLUSION We note increased mortality for emergency general surgery and acute myocardial infarction in patients receiving treatment at high-volume trauma centers, signifying underlying structural factors to broadly affect quality. Thus, decoupling trauma and emergency general surgery services may not meaningfully improve outcomes for emergency general surgery patients. Our findings have implications for the evolving specialty of emergency general surgery, especially for the safety and continued growth of the acute care surgery model.
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Affiliation(s)
- Amulya Vadlakonda
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Nam Yong Cho
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Zachary Tran
- Department of Surgery, Loma Linda University Health, Loma Linda, CA
| | - Joanna Curry
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Sara Sakowitz
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Jeffrey Balian
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Troy Coaston
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Areti Tillou
- Division of Trauma and Acute Care Surgery, University of California, Los Angeles, CA
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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Prosperi Desenzi Ciaralo P, Guerreiro Cardoso PF, Minamoto H, Bibas BJ, Ribeiro de Carvalho CR, Pego-Fernandes PM. Implementation and Results of a Dedicated Telemedicine Program ( TeleTrachea) for Patients with Tracheal Diseases. Telemed J E Health 2024; 30:1317-1324. [PMID: 38109228 DOI: 10.1089/tmj.2023.0524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
Background: Central airway diseases requiring frequent outpatient visits to a specialized medical center due to tracheal devices. Many of these patients have mobility and cognition restrictions or require specialized transport due to the need for supplemental oxygen. This study describes the implementation and results of a telemedicine program dedicated to patients with central airway diseases based in a Brazilian public health system. Methods: A retrospective study of telemedicine consultation for patients with central airway diseases referred to a public academic hospital between August 1, 2020 and August 1, 2022. The consultations occurred in a telemedicine department using the hospital's proprietary platform. Data retrieved consisted of demographics, disease characteristics, and the treatment modalities of the patients. The analysis included the savings in kilometers not traveled, the carbon footprint based on reducing CO2 emissions, and the cost savings in transportation. Results: A total of 1,153 telemedicine visits conducted in 516 patients (median age of 31.5 years). Two hundred ninety patients (56.2%) had a tracheal device (129 silicone T-Tube, 128 tracheostomy, and 33 endoprosthesis) and 159 patients (30.8%) had difficulties in transportation to the specialized medical center. Patients were served from 147 Brazilian cities from 22 states. The savings in kilometers traveled was 1,224,108.54 km, corresponding to a 250.14 ton reduction in CO2 emissions. The costs savings in transportation for the municipalities was BRL$ 1,272,283.78. Conclusions: Telemedicine consultations for patients with central airway diseases are feasible and safe. Cost savings and the possibility of disseminating specialized care make telemedicine a fundamental tool in current medical practice.
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Affiliation(s)
- Pedro Prosperi Desenzi Ciaralo
- Divisions of Thoracic Surgery, Instituto do Coracao do Hospital das Clinicas, HCFMUSP da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Paulo Francisco Guerreiro Cardoso
- Divisions of Thoracic Surgery, Instituto do Coracao do Hospital das Clinicas, HCFMUSP da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Helio Minamoto
- Divisions of Thoracic Surgery, Instituto do Coracao do Hospital das Clinicas, HCFMUSP da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Benoit Jacques Bibas
- Divisions of Thoracic Surgery, Instituto do Coracao do Hospital das Clinicas, HCFMUSP da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Carlos Roberto Ribeiro de Carvalho
- Divisions of Pulmonology, Instituto do Coracao do Hospital das Clinicas, HCFMUSP da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Paulo Manuel Pego-Fernandes
- Divisions of Thoracic Surgery, Instituto do Coracao do Hospital das Clinicas, HCFMUSP da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
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Sternick M, Licata A, Britt R. Outcomes of Small Bowel Obstructions by Admitting Specialty and Hospital Type. Am Surg 2023:31348231157865. [PMID: 36794820 DOI: 10.1177/00031348231157865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Small bowel obstructions (SBOs) account for a significant burden on the health care system. Should the ongoing trend of regionalizing medicine extend to these patients? We investigated if there is a benefit to admitting SBOs to larger teaching hospitals and to surgical services. METHODS We performed a retrospective chart review of 505 patients admitted to a Sentara Facility between 2012 and 2019 with a diagnosis of SBO. Patients between the ages of 18 and 89 were included. Patients were excluded if they required emergent operation. Outcomes were evaluated based on patient's admission either to a teaching or community hospital as well as the admitting service's specialty. RESULTS Of 505 patients admitted with a SBO, 351 (69.5%) were admitted to a teaching hospital. 392 (77.6%) patients were admitted to a surgical service. The average length of stay (LOS) (4 vs 7 days, P < .0001) and cost ($18,069.79 vs $26,458.20, P < .0001) were lower at teaching hospitals. The same trends in LOS (4 vs 7 days, P < .0001) and cost ($18,265.10 vs $29 944.82, P < .0001) were seen with surgical services. The 30-day readmission rate was higher in teaching hospitals (18.2% vs 11%, P = .0429), and no difference was seen in operative rate or mortality. DISCUSSION These data would suggest that there is a benefit to admitting SBO patients to larger teaching hospitals and to surgical services with regard to LOS and cost, suggesting that these patients might benefit from treatment at centers with emergency general surgery (EGS) Services.
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Affiliation(s)
- Molly Sternick
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Andrew Licata
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Rebecca Britt
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
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Adams U, Buckio J, Schreiber E, Cook A, Charles A. Same-Day Surgery Clinic: A model for improving access to care at academic medical centers. Am J Surg 2023; 225:374-377. [PMID: 36075762 DOI: 10.1016/j.amjsurg.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Best-practice models delivering surgical care in the preoperative setting are unknown. In April 2018, we established a Same-Day Clinic (SDC) to increase the access and efficiency of general surgical care delivery. METHODS This is a single-institution retrospective cohort study. We included patients who underwent elective laparoscopic cholecystectomy, inguinal or umbilical hernia repair. 112 patients were seen in the year prior to clinic creation; 84 were seen in the year following clinic creation. RESULTS After clinic creation, the percentage of patients referred following an emergency department encounter decreased from 33.4 to 17.9%. Patients referred from primary care encounters increased from 28.6 to 44%. Patients who underwent pre-referral imaging decreased from 58.9% to 44%. The SDC cohort was seen 11 days sooner (40 vs. 29d). CONCLUSION The SDC increases access and decreases wait times to surgical treatment. It strengthens referral networks for traditionally underserved populations and reduces the burden of non-necessary preoperative imaging.
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Affiliation(s)
- Ursula Adams
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA
| | - Joellen Buckio
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA
| | - Elizabeth Schreiber
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA
| | - Audrey Cook
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA
| | - Anthony Charles
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA.
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Zhu J, Lois AW, Gitonga B, Chen-Meekin JY, Williams EJ, Khandelwal S, Carrera Ceron R, Oelschlager BK, Wright AS. The impact of socioeconomic status on telemedicine utilization during the COVID-19 pandemic among surgical clinics at an academic tertiary care center. Surg Endosc 2022; 36:9304-9312. [PMID: 35332387 PMCID: PMC8945866 DOI: 10.1007/s00464-022-09186-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The COVID-19 pandemic caused many surgical providers to conduct outpatient evaluations using remote audiovisual conferencing technology (i.e., telemedicine) for the first time in 2020. We describe our year-long institutional experience with telemedicine in several general surgery clinics at an academic tertiary care center and examine the relationship between area-based socioeconomic measures and the likelihood of telemedicine participation. METHODS We performed a retrospective review of our outpatient telemedicine utilization among four subspecialty clinics (including two acute care and two elective surgery clinics). Geocoding was used to link patient visit data to area-based socioeconomic measures and a multivariable analysis was performed to examine the relationship between socioeconomic indicators and patient participation in telemedicine. RESULTS While total outpatient visits per month reached a nadir in April 2020 (65% decrease in patient visits when compared to January 2020), there was a sharp increase in telemedicine utilization during the same month (38% of all visits compared to 0.8% of all visits in the month prior). Higher rates of telemedicine utilization were observed in the two elective surgery clinics (61% and 54%) compared to the two acute care surgery clinics (14% and 9%). A multivariable analysis demonstrated a borderline-significant linear trend (p = 0.07) between decreasing socioeconomic status and decreasing odds of telemedicine participation among elective surgery visits. A sensitivity analysis to examine the reliability of this trend showed similar results. CONCLUSION Telemedicine has many patient-centered benefits, and this study demonstrates that for certain elective subspecialty clinics, telemedicine may be utilized as the preferred method for surgical consultations. However, to ensure the equitable adoption and advancement of telemedicine services, healthcare providers will need to focus on mitigating the socioeconomic barriers to telemedicine participation.
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Affiliation(s)
- Jay Zhu
- Department of Surgery, University of New Mexico School of Medicine, MSC10 5610, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
| | - Alex W Lois
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Baraka Gitonga
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Judy Y Chen-Meekin
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Estell J Williams
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Saurabh Khandelwal
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Rocio Carrera Ceron
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Brant K Oelschlager
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Andrew S Wright
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
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Abstract
Importance Hospitals with emergency surgical services provide essential care for a wide range of time-sensitive diseases. Commonly used measures of spatial access, such as distance or travel time, have been shown to underestimate disparities compared with more comprehensive metrics. Objective To examine population-level differences in spatial access to hospitals with emergency surgical capability across the US using enhanced 2-step floating catchment (E2SFCA) methods. Design, Setting, and Participants A cross-sectional study using the 2015 American Community Survey data. National census block group (CBG) data on community characteristics were paired with geographic coordinates of hospitals with emergency departments and inpatient surgical services, and hospitals with advanced clinical resources were identified. Spatial access was measured using the spatial access ratio (SPAR), an E2SFCA method that captures distance to hospital, population demand, and hospital capacity. Small area analyses were conducted to assess both the population with low access to care and community characteristics associated with low spatial access. Data analysis occurred from February 2021 to July 2022. Main Outcomes and Measures Low spatial access was defined by SPAR greater than 1.0 SD below the national mean (SPAR <0.3). Results In the 217 663 CBGs (median [IQR] age for CBGs, 39.7 [33.7-46.3] years), there were 3853 hospitals with emergency surgical capabilities and 1066 (27.7%) with advanced clinical resources. Of 320 million residents, 30.8 million (9.6%) experienced low access to any hospital with emergency surgical services, and 82.6 million (25.8%) to advanced-resource centers. Insurance status was associated with low access to care across all settings (public insurance: adjusted rate ratio [aRR], 1.21; 95% CI, 1.12-1.25; uninsured aRR, 1.58; 95% CI, 1.52-1.64). In micropolitan and rural areas, high-share (>75th percentile) Hispanic and other (Asian; American Indian, Alaska Native, or Pacific Islander; and 2 or more racial and ethnic minority groups) communities were also associated with low access. Similar patterns were seen in access to advanced-resource hospitals, but with more pronounced racial and ethnic disparities. Conclusions and Relevance In this cross-sectional study of access to surgical care, nearly 1 in 10 US residents experienced low spatial access to any hospital with emergency surgical services, and 1 in 4 had low access to hospitals with advanced clinical resources. Communities with high rates of uninsured or publicly insured residents and racial and ethnic minority communities in micropolitan and rural areas experienced the greatest risk of limited access to emergency surgical care. These findings support the use of E2SFCA models in identifying areas with low spatial access to surgical care and in guiding health system development.
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Affiliation(s)
- Marta L. McCrum
- Division of General Surgery, University of Utah, Salt Lake City
| | - Neng Wan
- Department of Geography, University of Utah, Salt Lake City
| | - Jiuying Han
- Department of Geography, University of Utah, Salt Lake City
| | | | - Joshua J. Horns
- Surgical Population Analysis Research Core, Department of Surgery, University of Utah, Salt Lake City
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Abstract
OBJECTIVE To determine whether rural Medicare FFS beneficiaries are more likely to be admitted to an urban hospital in 2018 than in 2010. DATA SOURCES We combined data from the 2010 to 2018 Hospital Service Area File (HSAF) and the 2010-2017 American Hospital Association (AHA) survey. STUDY DESIGN We conducted a fixed-effects negative-binomial regression to determine whether urban hospital admissions from rural ZIP codes were increasing over time. We also conducted an exploratory geographically weighted regression. DATA COLLECTION We transformed the HSAF data into a ZIP code-level file with all rural ZIP codes. We defined rural as having a Rural-Urban Commuting Area (RUCA) code ≥4. A hospital's system affiliation status was incorporated from the AHA survey. PRINCIPAL FINDINGS Controlling for distance to the nearest hospitals, an increase of 1 year was associated with a 2.0% increase (p < 0.001) in the number of admissions to urban hospitals from each rural ZIP code. New system affiliation of the nearest rural hospital was associated with an increase of 1.7% (p < 0.001). CONCLUSIONS Even when controlling for distance to the nearest rural hospital (which reflects hospital closures), rural patients were increasingly likely to be admitted to an urban hospital.
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Affiliation(s)
- Hannah R. Friedman
- Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
- The Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - George Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
- The Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Cralley AL, Burlew CC, Fox CJ, Pieracci FM, Platnick KBK, Campion EM, Cohen MJ, Moore EE, Lawless RA. An Unencumbered Acute Care Surgeon Improves Delivery of Emergent Surgical Care for Cholecystectomy Patients. JSLS 2022; 26:JSLS.2022.00045. [PMID: 36212183 PMCID: PMC9521635 DOI: 10.4293/jsls.2022.00045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Many patients utilize the Emergency Room (ER) for primary care, resulting in overburdened ERs, strained resources, and delays in care. To combat this, many centers have adopted a Trauma/Acute Care Surgery (TACS) service providing specialty surgeons whose primary work is the unencumbered surgical availability to emergency surgery patients. To evaluate our programs’ efficacy, we investigated cholecystectomies as a common urgent procedure representative of services provided. We hypothesized that the adoption of a TACS service would result in improved access to care as evidence by decreased ER visits prior to cholecystectomy, improved time to cholecystectomy, and decreased hospital length of stay (LOS). Methods: All patients that underwent urgent cholecystectomy from January 1, 2018 to December 31, 2018 were reviewed. The unencumbered TACS surgeon was implemented on July 1, 2018. Prior ER visits involving biliary symptoms, time from admission to cholecystectomy, and hospital LOS were compared. Results: Of the 322 urgent cholecystectomies over the study period, 165 were performed prior and 157 following adoption of the TACS structure. The average number of ER visits for biliary symptoms prior to cholecystectomy decreased from 1.4 to 1.2 (p = 0.01). Time from admission to cholecystectomy was 28.3 hours and 27.3 hours respectively (p = 0.74). Average LOS decreased following the restructure (3.1 vs 2.5 days; p = 0.03). Conclusion: Implementation of an unencumbered TACS surgeon managing urgent surgical disease improves access to and delivery of surgical services for cholecystectomy patients in a safety net, level one trauma center. Further research is necessary to determine potential improvements in hospital cost and patient satisfaction.
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Affiliation(s)
- Alexis L. Cralley
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Clay C. Burlew
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Charles J. Fox
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Fredric M. Pieracci
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - K. Barry K. Platnick
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Eric M. Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Mitchell J. Cohen
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Ernest E. Moore
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Ryan A. Lawless
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
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Di Pietro Martinelli C, Haltmeier T, Lavanchy JL, Perrodin SF, Candinas D, Schnüriger B. Work Characteristics of Acute Care Surgeons at a Swiss Tertiary Care Hospital: A Prospective One-Month Snapshot Study. World J Surg 2021. [PMID: 34677655 DOI: 10.1007/s00268-021-06350-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Li HW, Scanlon ML, Kisilu N, Litzelman DK. The role of community health workers in the surgical cascade: a scoping review. Hum Resour Health 2021; 19:122. [PMID: 34602064 PMCID: PMC8489043 DOI: 10.1186/s12960-021-00659-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 09/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade. METHODS We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data. RESULTS The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event. CONCLUSION While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade.
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Affiliation(s)
- Helen W. Li
- Department of Surgery, Washington University School of Medicine in St Louis, St. Louis, MO United States of America
| | - Michael L. Scanlon
- Indiana University Center for Global Health, 702 Rotary Circle, Suite RO 101, Indianapolis, IN 46202 United States of America
| | - Nicholas Kisilu
- Department of General Surgery and Anesthesiology, Moi University School of Medicine, Eldoret, Kenya
| | - Debra K. Litzelman
- William M. Tierney Center for Health Services Research, Regenstrief Institute, Inc. and Indiana University School of Medicine, 1101 West 10th Street, Indianapolis, IN 46202 United States of America
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Rushing AP, Strassels SA, Ricci KB, Daniel VT, Ingraham AM, Paredes AZ, Diaz A, Oslock WM, Baselice HE, Heh VK, Santry HP. In-house intensivist presence does not affect mortality in select emergency general surgery patients. J Trauma Acute Care Surg 2021; 91:719-727. [PMID: 34238856 DOI: 10.1097/ta.0000000000003343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis. METHODS Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses. RESULTS We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality. CONCLUSION Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes. LEVEL OF EVIDENCE Therapeutic, level III.
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Affiliation(s)
- Amy P Rushing
- From the Department of Surgery-Trauma (A.P.R.), University Hospitals, Cleveland; Department of Surgery (S.A.S., A.Z.P., A.D., H.E.B., V.K.H.), Ohio State University Wexner Medical Center; Department of Surgery (K.B.R.), Johns Hopkins Medical School, Baltimore, MD; Department of Surgery (W.M.O.), University of Alabama, Birmingham, AL; Consulting Studio (H.P.S.), NBBJ Design LLC, Columbus, OH; Department of Trauma Surgery (H.P.S.), Kettering Medical Center, Kettering, OH; Center for Surgical Health Assessment, Research and Policy (S.A.S., K.B.R., A.Z.P., A.D., H.E.B., V.K.H., H.P.S.), Ohio State University, Columbus, Ohio; Department of Dermatology (V.T.D.), University of Massachusetts Medical School, Worcester MA; Department of Surgery (A.M.I.), University of Wisconsin, Madison, Wisconsin; and Ohio State University College of Medicine (W.M.O.), Columbus, Ohio
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Teng CY, Davis BS, Rosengart MR, Carley KM, Kahn JM. Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions. JAMA Netw Open 2021; 4:e2123389. [PMID: 34468755 PMCID: PMC8411299 DOI: 10.1001/jamanetworkopen.2021.23389] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood. OBJECTIVE To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021. EXPOSURES Hospital-level measures of size (total bed capacity), resources (intensive care unit [ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (risk-adjusted failure to rescue and in-hospital mortality). MAIN OUTCOMES AND MEASURES The main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes. RESULTS Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg, >25 beds vs 0-10 beds: β = 1.67 [95% CI, 1.16-2.17]; P < .001), and higher EGS volume (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.78 [95% CI, 0-1.57]; P = .01). However, a higher log-transformed centrality ratio was not associated with better outcomes, such as lower in-hospital mortality (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.30 [95% CI, -0.09 to 0.68]; P = .83) and lower failure to rescue (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = -0.50 [95% CI, -1.13 to 0.12]; P = .27). CONCLUSIONS AND RELEVANCE In this study, EGS transfers were directed to high-volume hospitals with more resources but were not necessarily directed to hospitals with better clinical outcomes. Optimizing transfer destination in the interhospital transfer network has the potential to improve EGS outcomes.
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Affiliation(s)
- Cindy Y. Teng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Billie S. Davis
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Matthew R. Rosengart
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathleen M. Carley
- Department of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania
- Department of Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
- Department of Public Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Berg A, Rosenzweig M, Kuo YH, Onayemi A, Mohidul S, Moen M, Sciarretta J, Davis JM, Ahmed N. The results of rapid source control laparotomy or open abdomen for acute diverticulitis. Langenbecks Arch Surg 2021; 407:259-265. [PMID: 34455491 PMCID: PMC8402969 DOI: 10.1007/s00423-021-02304-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 08/16/2021] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Rapid source control laparotomy (RSCL) for the management of non-traumatic intra-abdominal emergencies has increased over the past 25 years when it was advocated for trauma patients. Little data, however, support its widespread use. We hypothesize that the patients with RSCL will have poorer outcomes than those treated with primary fascial closure (PFC). METHODS Patients operated for acute diverticulitis from 2014 to 2016 using The American College of Surgeons sponsored National Surgical Quality Improvement Program (NSQIP) data were reviewed. Two groups were identified: PFC, patients with their closed fascia but skin left open (PFC) and RSCL, patients with their left open fascia after the initial operation. The primary outcome of the study was 30-day mortality, with secondary analyses evaluating complications, discharge location and length of stay. Univariate analysis was initially performed followed by propensity score matching. RESULTS A total of 460 patients were surgically treated for Hinchey IV diverticulitis of whom 101 (21.9%) had RSCL. The length of stay of the RSCL patients was significantly longer (15 versus 12 days, p, 0.02) than patients in the PFC group. Similarly, the discharge destination for the PFC group was twice as likely to be discharged home as the RSCL group. CONCLUSION RSCL for acute diverticulitis is a widely used but is associated with prolonged hospitalizations resulting in high rates of discharge to skilled nursing or rehabilitation facilities. Its routine use for diverticulitis should be limited.
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Affiliation(s)
- Arthur Berg
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Matthew Rosenzweig
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Yen-Hong Kuo
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Ayolola Onayemi
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | | | - Micaela Moen
- Grand Strand Medical Center, Myrtle Beach, SC, USA
| | - Jason Sciarretta
- Emory School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - John Mihran Davis
- South Shore University Hospital - Northwell Health, Bay Shore, NY, USA. .,South Shore University Hospital - Northwell Health, 301 East Main Street, NY, 17061, Bay Shore, USA.
| | - Nasim Ahmed
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
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Valle JA, Li Z, Kosinski AS, Nelson AJ, Vemulapalli S, Cleveland J, Fullerton D, Messenger JC, Rove JY, Bricker RS, Bradley SM, Masoudi FA, Yeh RW, Armstrong EJ, Waldo SW, Carroll JD. Dissemination of Transcatheter Aortic Valve Replacement in the United States. J Am Coll Cardiol 2021; 78:794-806. [PMID: 34412813 DOI: 10.1016/j.jacc.2021.06.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Societal guidelines and payor coverage decisions for transcatheter aortic valve replacement (TAVR) attempt to strike a balance between providing access and maintaining quality. The extent to which dissemination of TAVR has achieved these ideals remains unknown. OBJECTIVES This study sought to define patterns of TAVR dissemination in the United States and their influence on outcomes. METHODS Using data from the TVT (Transcatheter Valvular Therapy) registry, this study identified TAVR sites from 2011 to 2018 and calculated drive-times from existing to new sites. In a contemporary cohort, this study compared site and patient characteristics by annual case volume and density of sites per million Medicare beneficiaries. Using hierarchical regression and Cox methods, this study determined the association between case volumes, site density, and changes in volume and density with patient risk profiles and outcomes. RESULTS TAVR sites participating in the TVT registry increased from 198 to 556 from 2011 to 2018. Median drive-time from existing to new sites decreased from 403 minutes (interquartile range: 211-587 minutes) to 26 minutes (interquartile range: 17-48 minutes). In a contemporary cohort, higher site density was associated with lower procedural risk as well as with an increased hazard of 30-day risk-adjusted mortality (P = 0.017). Similarly, longitudinal increases in site density over time were associated with a higher hazard of 30-day (P = 0.011) and 1-year (P = 0.013) mortality. CONCLUSIONS TAVR has expanded significantly over time, but with regional clustering of sites. Although procedural risk is lower at higher density sites, these sites demonstrate an increased hazard of mortality. These findings suggest that the expansion of TAVR services in the United States may have had unintended consequences on procedural quality.
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15
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Mehta R, Tsilimigras DI, Paredes AZ, Hyer M, Dillhoff M, Cloyd JM, Ejaz A, Tsung A, Pawlik TM. County-Level Variation in Utilization of Surgical Resection for Early-Stage Hepatopancreatic Cancer Among Medicare Beneficiaries in the USA. J Gastrointest Surg 2021; 25:1736-44. [PMID: 32918677 DOI: 10.1007/s11605-020-04778-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Geographic variations in access to care exist in the USA. We sought to characterize county-level disparities relative to access to surgery among patients with early-stage hepatopancreatic (HP) cancer. METHODS Data were extracted from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Linked database from 2004 to 2015 to identify patients undergoing surgery for early-stage HP cancer . County-level information was acquired from the Area Health Resources Files (AHRF). Multivariable logistic regression analysis was performed to assess factors associated with utilization of HP surgery on the county level. RESULTS Among 13,639 patients who met inclusion criteria, 66.9% (n = 9125) were diagnosed with pancreatic cancer and 33.1% (n = 4514) of patients had liver cancer. Among patients diagnosed with early-stage liver and pancreas malignancy, two-thirds (n = 8878, 65%) underwent surgery. Marked county-level variation in the utilization of surgery was noted among patients with early-stage HP cancer ranging from 57.1% to more than 83.3% depending on which county a patient resided. After controlling for patient and tumor-related characteristics, counties with the highest quartile of patients living below the poverty level had 35% lower odds of receiving surgery for early stage HP cancer compared patients who lived in a county with the lowest proportion of patients below the poverty line (OR 0.65, 95% CI 0.55-0.77). In addition, patients residing in counties with the highest surgeon-to-population ratio (OR 2.01, 95% CI 1.52-2.65), as well as the highest hospital bed-to-population ratio (OR 1.29, 95% CI 1.07-1.54), were more likely to undergo surgical treatment for an early-stage HP malignancy. CONCLUSION Area-level variations among patients undergoing surgery for early-stage HP cancer were mainly due to differences in structural measures and county-level factors. Policies targeting high-poverty counties and improvement in structural measures may reduce variations in utilization of surgery among patients diagnosed with early-stage HP cancer.
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Tian Y, Ingram MCE, Raval MV. National Trends and Disparities in the Diffusion of Laparoscopic Surgery for Children in the United States. J Laparoendosc Adv Surg Tech A 2021; 31:1061-1066. [PMID: 34152864 DOI: 10.1089/lap.2021.0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Laparoscopic surgery has become the standard of care for many surgical treatments. The diffusion of laparoscopy has been investigated for adult patient populations but is still unknown for pediatric populations. This study sought to describe national trends in diffusion of laparoscopic surgery for common pediatric conditions and identify disparities in use of laparoscopic surgery. Study Design: A retrospective analysis of serial cross-sectional data was performed using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 1997 to 2016. Pediatric patients (ages ≤18) undergoing appendectomy, cholecystectomy, fundoplication, or inguinal hernia repair were identified. The diffusion of laparoscopy for each procedure was measured using the proportion of laparoscopic surgeries over years. Results: National trends demonstrate increases in the use of laparoscopy for children over the past two decades from 13.4% to 88.7% for appendectomy, from 82.6% to 94.9% for cholecystectomy, from 7.4% to 77.4% for fundoplication, and from 1.5% to 23.5% for repair of inguinal hernia (P < .001). Disparities in diffusion of laparoscopy were found from various pediatric populations, and the disparities varied by specific procedures and years. In particular, the proportion of laparoscopic appendectomy in 1997 was 11.3% at urban teaching hospitals and was 13.9% at rural hospitals (P = .01), while the proportions in 2016 increased to 90.8% at urban teaching hospitals versus 71.3% at rural hospitals (P < .001). Conclusions: Laparoscopy has become the standard surgical care for common pediatric surgical conditions. Widening disparities in use of laparoscopic surgery for pediatric populations appear between urban teaching hospitals and rural hospitals.
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Affiliation(s)
- Yao Tian
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann & Robert H. Lurie, Children's Hospital, Chicago, Illinois, USA
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann & Robert H. Lurie, Children's Hospital, Chicago, Illinois, USA
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17
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Leech MM, Briggs A, Loehrer AP. Surgical Diseases are Common and Complicated for Criminal Justice Involved Populations. J Surg Res 2021; 265:27-32. [PMID: 33872846 DOI: 10.1016/j.jss.2021.02.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 01/15/2021] [Accepted: 02/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND At any given time, almost 2 million individuals are in prisons or jails in the United States. Incarceration status has been associated with disproportionate rates of cancer and infectious diseases. However, little is known about the burden emergency general surgery (EGS) in criminal justice involved (CJI) populations. MATERIALS AND METHODS The California Office of Statewide Health Planning and Development (OSHPD) database was used to evaluate all hospital admissions with common EGS diagnoses in CJI persons from 2012-2014. The population of CJI individuals in California was determined using United States Bureau of Justice Statistics data. Primary outcomes were rates of admission and procedures for five common EGS diagnoses, while the secondary outcome was probability of complex presentation. RESULTS A total of 4,345 admissions for CJI patients with EGS diagnoses were identified. The largest percentage of EGS admissions were with peptic ulcer disease (41.0%), followed by gallbladder disease (27.5%), small bowel obstruction (14.0%), appendicitis (13.8%), and diverticulitis (10.5%). CJI patients had variable probabilities of receipt of surgery depending on condition, ranging from 6.2% to 90.7%. 5.6% to 21.0% of admissions presented with complicated disease, the highest being with peptic ulcer disease and appendicitis. CONCLUSION Admissions with EGS diagnoses were common and comparable to previously published rates of disease in general population. CJI individuals had high rates of complicated presentation, but low rates of surgical intervention. More granular evaluation of the burden and management of these common, morbid, and costly surgical diagnoses is essential for ensuring timely and quality care delivery for this vulnerable population.
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18
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Mahoney ST, Irish W, Strassle PD, Schroen AT, Freischlag JA, Tuttle-Newhall JEB, Brownstein MR. Practice Characteristics and Job Satisfaction of Private Practice and Academic Surgeons. JAMA Surg 2021; 156:247-254. [PMID: 33326032 DOI: 10.1001/jamasurg.2020.5670] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Private practice and academic surgery careers vary significantly in their daily routine, compensation schemes, and definition of productivity. Data are needed regarding the practice characteristics and job satisfaction of these career paths for surgeons and trainees to make informed career decisions and to identify modifiable factors that may be associated with the health of the surgical workforce. Objective To obtain and compare the differences in practice characteristics and career satisfaction measures between academic and private practice surgeons. Design, Setting, and Participants In this cross-sectional survey performed from June 4 to August 1, 2018, an online survey accommodating smartphone, tablet, and desktop formats was distributed by email to 25 748 surgeons who were actively practicing fellows of the American College of Surgeons; had completed a general surgery residency or categorical fellowship in plastic, cardiothoracic, or vascular surgery; and had an active email address on file. Main Outcomes and Measures Demographic, training, and current practice characteristics were obtained, and satisfaction measures were measured on a 5-point Likert scale and compared by surgeon type. Nonresponse weights adjusted for respondent sex, age, and presence of subspecialty training between respondents and the total surveyed American College of Surgeons population. Results There were 3807 responses (15% response rate) from surgeons: 1735 academic surgeons (1390 men [80%]; median age, 53 years [interquartile range (IQR), 44-61 years]) and 1464 private practice surgeons (1276 men [87%]; median age, 56 years [IQR, 48-62 years]); 589 surgeons who reported being neither an academic surgeon nor a private practice surgeon and 19 surgeons who did not respond to questions on their practice type were excluded. Academic surgeons reported working a median of 59 hours weekly (IQR, 38-65 hours) compared with 57 hours weekly (IQR, 45-65 hours) for private practice surgeons. Academic surgeons reported more weekly hours performing nonclinical work than did private practice surgeons (24 hours [IQR, 14-38 hours] vs 9 hours [IQR, 4-17 hours]; P < .001). Academic surgeons were more likely than private practice surgeons to be satisfied with their career as a surgeon (1448 of 1706 [85%] vs 1109 of 1420 [78%]; P < .001) and their financial compensation (997 of 1703 [59%] vs 546 of 1416 [39%]; P < .001). Academic surgeons were less likely than private practice surgeons to feel that competition with other surgeons is a threat to financial security (341 of 1705 [20%] vs 559 of 1422 [39%]; P < .001) and less likely to feel that malpractice experience has decreased job satisfaction (534 of 1703 [31%] vs 686 of 1413 [49%]; P < .001). Conclusions and Relevance This study suggests that, although overall surgeon satisfaction was high, academic surgeons reported higher career satisfaction on several measures when compared with private practice surgeons. Advocacy for private practice surgeons is important to encourage career longevity and sustain US surgeon workforce needs.
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Affiliation(s)
- Stephen T Mahoney
- Department of Surgery, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan
| | - William Irish
- Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Paula D Strassle
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill.,Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Julie A Freischlag
- Department of Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
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Ingraham AM, Chaffee SM, Ayturk MD, Heh VK, Kiefe CI, Santry HP. Gaps in Emergency General Surgery Coverage in the United States. Ann Surg Open 2021; 2:e043. [PMID: 34485983 PMCID: PMC8409136 DOI: 10.1097/as9.0000000000000043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/21/2021] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Despite three million adults in the United States (US) being admitted annually for emergency general surgery (EGS) conditions, which disproportionately affect vulnerable populations, we lack an understanding of the barriers to round-the-clock EGS care. Our objective was to measure gaps in round-the-clock EGS care. METHODS From August 2015 to December 2015, we surveyed all US-based, adult acute care general hospitals that have an emergency room and ≥1 operating room and provide EGS care, utilizing paper and electronic methods. Surgeons or chief medical officers were queried regarding EGS practices. RESULTS Of 2,811 hospitals, 1,634 (58.1%) responded; 279 (17.1%) were unable to always provide round-the-clock EGS care. Rural location, smaller bed size, and non-teaching status were associated with lack of round-the-clock care. Inconsistent surgeon coverage was the primary reason for lacking round-the-clock EGS care (n=162; 58.1%). However, lack of a tiered system for booking emergency cases, no anesthesia availability overnight, and no stipend for EGS call were also associated with the inability to provide round-the-clock EGS care. DISCUSSION We found significant gaps in access to EGS care, often attributable to workforce deficiencies.
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Affiliation(s)
| | - Scott M. Chaffee
- Department of Surgery, The Ohio State University, Columbus, OH
- Center for Surgical Health Assessment, Research, and Policy (SHARP), The Ohio State University, Columbus, OH
| | - M. Didem Ayturk
- §Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Victor K. Heh
- Department of Surgery, The Ohio State University, Columbus, OH
- Center for Surgical Health Assessment, Research, and Policy (SHARP), The Ohio State University, Columbus, OH
| | - Catarina I. Kiefe
- §Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Heena P. Santry
- Department of Surgery, The Ohio State University, Columbus, OH
- Center for Surgical Health Assessment, Research, and Policy (SHARP), The Ohio State University, Columbus, OH
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Diaz A, Ricci KB, Rushing AP, Ingraham AM, Daniel VT, Paredes AZ, Baselice HE, Oslock WM, Heh V, Strassels SA, Santry HP. Re-examining "Never Letting the Sun Rise or Set on a Bowel Obstruction" in the Era of Acute Care Surgery. J Gastrointest Surg 2021; 25:512-22. [PMID: 32043222 DOI: 10.1007/s11605-019-04496-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 12/05/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) no longer mandates urgent surgical evaluation raising the question of the role of operating room (OR) access on SBO outcomes. METHODS Data from our 2015 survey on emergency general surgery (EGS) practices, including queries on OR availability and surgical staffing, were anonymously linked to adult SBO patient data from 17 Statewide Inpatient Databases (SIDs). Univariate and multivariable associations between OR access and timing of operation, complications, length of stay (LOS), and in-hospital mortality were measured. RESULTS Of 32,422 SBO patients, 83% were treated non-operatively. Operative patients were older (median 66 vs 65 years), had more comorbidities (53% vs 46% with ≥ 3), and experienced more systemic complications (36% vs 23%), higher mortality (2.8% vs 1.4%), and longer LOS (median 10 vs 4 days). Patients had lower odds of operation if treated at hospitals lacking processes to tier urgent cases (aOR 0.90, 95% CI [0.83-0.99]) and defer elective cases (aOR 0.87 [0.80-0.94]). Patients had higher odds of operation if treated at hospitals with surgeons sometimes (aOR 1.14 [1.04-1.26]) or rarely/never (aOR 1.16 [1.06-1.26]) covering EGS at more than one location compared to always. Odds of systemic complication (OR 2.0 [1.6-2.4]), operative complication (OR 1.5 [1.2-1.8]), and mortality were increased for very late versus early operation (OR 2.6 [1.7-4.0]). CONCLUSIONS Although few patients with SBO require emergency surgery, we identified EGS structures and processes that are important for providing timely and appropriate intervention for patients whose SBO remains unresolved and requires surgery.
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21
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Hatchimonji JS, Kaufman EJ, Dowzicky PM, Scantling DR, Holena DN. Efficient evaluation of center-level emergency surgery performance using a high-yield procedure set: A step towards an EGS registry. Am J Surg 2021; 222:625-630. [PMID: 33509544 DOI: 10.1016/j.amjsurg.2021.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/10/2021] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) lacks mechanisms to compare performance between institutions. Focusing on higher-risk procedures may efficiently identify outliers. METHODS EGS patients were identified from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Risk-adjusted mortality was calculated as an O:E ratio, generating expected mortality from a model including demographic and procedural factors. Outliers were centers whose 90% confidence intervals excluded 1. This was repeated in several subsets, to determine if these yielded outliers similar to the overall dataset. RESULTS We identified 45,430 EGS patients. Overall, 3 high performing centers and 5 low performing centers were identified. Exclusion of appendectomies and cholecystectomies resulted in a remaining data set of 13,569 patients (29.9% of the overall data set), with 2 high performers and 5 low performers. One low performer in the limited data set was not identified in the overall set. CONCLUSION Evaluation of 5 procedures, making up less than a third of EGS, identifies most outliers. A streamlined monitoring procedure may facilitate maintenance of an EGS registry.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Phillip M Dowzicky
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Dane R Scantling
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Daniel N Holena
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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22
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Ricci KB, Oslock WM, Ingraham AM, Rushing AP, Diaz A, Paredes AZ, Daniel VT, Collins CE, Heh VK, Baselice HE, Strassels SA, Caterino JM, Santry HP. Importance of Radiologists in Optimizing Outcomes for Older Americans with Acute Abdomen. J Surg Res 2021; 261:361-368. [PMID: 33493888 DOI: 10.1016/j.jss.2020.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/06/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients presenting with acute abdominal pain often undergo a computed tomography (CT) scan as part of their diagnostic workup. We investigated the relationship between availability, timeliness, and interpretation of CT imaging and outcomes for life-threatening intra-abdominal diseases or "acute abdomen," in older Americans. METHODS Data from a 2015 national survey of 2811 hospitals regarding emergency general surgery structures and processes (60.1% overall response, n = 1690) were linked to 2015 Medicare inpatient claims data. We identified beneficiaries aged ≥65 admitted emergently with a confirmatory acute abdomen diagnosis code and operative intervention on the same calendar date. Multivariable regression models adjusted for significant covariates determined odds of complications and mortality based on CT resources. RESULTS We identified 9125 patients with acute abdomen treated at 1253 hospitals, of which 78% had ≥64-slice CT scanners and 85% had 24/7 CT technicians. Overnight CT reads were provided by in-house radiologists at 14% of hospitals and by teleradiologists at 66%. Patients were predominantly 65-74 y old (43%), white (88%), females (60%), and with ≥3 comorbidities (67%) and 8.6% died. STAT radiology reads by a board-certified radiologist rarely/never available in 2 h was associated with increased odds of systemic complication and mortality (adjusted odds ratio 2.6 [1.3-5.4] and 2.3 [1.1-4.8], respectively). CONCLUSIONS Delays obtaining results are associated with adverse outcomes in older patients with acute abdomen. This may be due to delays in surgical consultation and time to source control while waiting for imaging results. Processes to ensure timely interpretation of CT scans in patients with abdominal pain may improve outcomes in high-risk patients.
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Affiliation(s)
- Kevin B Ricci
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | | | | | - Amy P Rushing
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Adrian Diaz
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Anghela Z Paredes
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Vijaya T Daniel
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Courtney E Collins
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Victor K Heh
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Holly E Baselice
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Scott A Strassels
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Jeffrey M Caterino
- Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Heena P Santry
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio.
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McCrum ML, Davis KA, Kaafarani HM, Santry HP, Shafi S, Crandall ML. Current opinion on emergency general surgery transfer and triage criteria. J Trauma Acute Care Surg 2020; 89:e71-7. [PMID: 32467469 DOI: 10.1097/TA.0000000000002806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Hatchimonji JS, Ma LW, Kaufman EJ, Dowzicky PM, Scantling DR, Yang W, Holena DN. Differences Between Center-level Outcomes in Emergency and Elective General Surgery. J Surg Res 2020; 261:1-9. [PMID: 33387728 DOI: 10.1016/j.jss.2020.11.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/22/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Center-level outcome metrics have long been tracked in elective surgery (ELS). Despite recent interest in measuring emergency general surgery (EGS) quality, centers are often compared based on elective or combined outcomes. Therefore, quality of care for emergency surgery specifically is unknown. METHODS We extracted data on EGS and ELS patients from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Centers that performed >100 ELS and EGS operations were included. Risk-adjusted mortality, complication, and failure to rescue (FTR, death after complication) rates were calculated and observed-to-expected ratios were calculated by center for ELS and EGS patients. Centers were determined to be high or low outliers if the 90% CI for the observed: expected ratio excluded 1. We calculated the frequency with which centers demonstrated a different performance status between EGS and ELS. Kendall's tau values were calculated to assess for correlation between EGS and ELS status. RESULTS A total of 204 centers with 45,500 EGS cases and 49,380 ELS cases met inclusion criteria. Overall mortality, complication, and FTR rates were 1.7%, 8.0%, and 14.5% respectively. There was no significant correlation between mortality performance in EGS and ELS, with 36 centers in a different performance category (high outlier, low outlier, as expected) in EGS than in ELS. The correlation for complication rates was 0.20, with 60 centers in different categories for EGS and ELS. For FTR rates, there was no correlation, with 16 centers changing category. CONCLUSIONS There was minimal correlation between outcomes for ELS and EGS. High performers in one category were rarely high performers in the other. There may be important differences between the processes of care that are important for EGS and ELS outcomes that may yield meaningful opportunities for quality improvement.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Lucy W Ma
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Phillip M Dowzicky
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dane R Scantling
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N Holena
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Santry HP, Strassels SA, Ingraham AM, Oslock WM, Ricci KB, Paredes AZ, Heh VK, Baselice HE, Rushing AP, Diaz A, Daniel VT, Ayturk MD, Kiefe CI. Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach. BMC Med Res Methodol 2020; 20:247. [PMID: 33008294 PMCID: PMC7532630 DOI: 10.1186/s12874-020-01096-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).
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Affiliation(s)
- Heena P. Santry
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 614, Columbus, OH 43210 USA
| | - Scott A. Strassels
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Angela M. Ingraham
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, Madison, WI USA
| | - Wendelyn M. Oslock
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Kevin B. Ricci
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Anghela Z. Paredes
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Victor K. Heh
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Holly E. Baselice
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Amy P. Rushing
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Adrian Diaz
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Vijaya T. Daniel
- Department of Surgery, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - M. Didem Ayturk
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - Catarina I. Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
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Ross JT, Liang NE, Lebares CC, Carter JT, Harris HW, Cello JP, Rogers SJ, Lin MYC. Upper Gastrointestinal Endoscopy in an Academic General Surgical Program: Implications for Acute Care Surgeons. Surg Innov 2020; 27:669-674. [PMID: 32894031 DOI: 10.1177/1553350620957802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Esophagogastroduodenoscopy (EGD) is an important tool in the evolving specialty of acute care surgery (ACS). Understanding the types of nonelective EGDs performed by ACS groups is important for the development of ACS programs and the training of future general surgeons. Methods. We conducted a retrospective review of all EGDs performed by ACS surgeons at a single urban academic center over a 5-year period (January 2013-December 2018). Results. A total of 495 EGDs were performed, of which 129 (26%) were urgent, nonelective procedures. Patients who underwent urgent EGD were younger than those who underwent elective procedures (median 55 vs 60 years, P = .03), had higher American Society of Anesthesiologists (ASA) classes (median ASA 3 vs 2, P = .0002), and longer hospital stays (median 5 days vs 0 days, P < .0001). The most common indications for urgent endoscopies were the management of leak, dysphagia, or stenosis in patients with a history of foregut surgery, followed by the management of esophageal perforation. The success rate of endoscopic therapy was high (median 88%, interquartile range (IQR) 78-89%). However, some patients required multiple interventions (median 1, IQR 1-3), and patients treated for leaks were less likely to be successfully treated with endoscopic therapy alone than patients treated for other indications (success rate 65% vs 88%, P = .003). Conclusions. Our experience suggests that EGD has an important role in current ACS practice and that endoscopic management is safe and effective in a range of urgent surgical scenarios. Future ACS surgeons should be facile with endoscopic techniques.
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Affiliation(s)
- James T Ross
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Norah E Liang
- School of Medicine, 8785University of California San Francisco, San Francisco, CA, USA
| | - Carter C Lebares
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Jonathan T Carter
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Hobart W Harris
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - John P Cello
- Department of Medicine, Division of Gastroenterology, 8785University of California San Francisco, San Francisco, CA, USA
| | - Stanley J Rogers
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Matthew Y C Lin
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
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Oslock WM, Ricci KB, Ingraham AM, Rushing AP, Baselice HE, Paredes AZ, Heh VK, Byrd CA, Strassels SA, Santry HP. Role of interprofessional teams in emergency general surgery patient outcomes. Surgery 2020; 168:347-353. [DOI: 10.1016/j.surg.2020.04.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/09/2020] [Accepted: 04/15/2020] [Indexed: 11/30/2022]
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Tameron AM, Ricci KB, Oslock WM, Rushing AP, Ingraham AM, Daniel VT, Paredes AZ, Diaz A, Collins CE, Heh VK, Baselice HE, Strassels SA, Santry HP. The association between self-declared acute care surgery services and critical care resources: Results from a national survey. J Crit Care 2020; 60:84-90. [PMID: 32769008 DOI: 10.1016/j.jcrc.2020.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/27/2020] [Accepted: 04/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE We examined differences in critical care structures and processes between hospitals with Acute Care Surgery (ACS) versus general surgeon on call (GSOC) models for emergency general surgery (EGS) care. METHODS 2811 EGS-capable hospitals were surveyed to examine structures and processes including critical care domains and ACS implementation. Differences between ACS and GSOC hospitals were compared using appropriate tests of association and logistic regression models. RESULTS 272/1497 hospitals eligible for analysis (18.2%) reported they use an ACS model. EGS patients at ACS hospitals were more likely to be admitted to a combined trauma/surgical ICU or a dedicated surgical ICU. GSOC hospitals had lower adjusted odds of having 24-h ICU coverage, in-house intensivists or respiratory therapists, and 4/6 critical-care protocols. CONCLUSIONS Critical care delivery is a key component of EGS care. While harnessing of critical care structures and processes varies across hospitals that have implemented ACS, overall ACS models of care appear to have more robust critical care practices.
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Affiliation(s)
- Ashley M Tameron
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA
| | - Kevin B Ricci
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Wendelyn M Oslock
- Ohio State University College of Medicine, 370 W 9th Avenue, Columbus, OH, USA
| | - Amy P Rushing
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Angela M Ingraham
- University of Wisconsin, Department of Surgery, 600 Highland Avenue, Madison, WI, USA
| | - Vijaya T Daniel
- University of Massachusetts Medical School, Department of Surgery, 55 Lake Avenue, Worcester, MA, USA
| | - Anghela Z Paredes
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Adrian Diaz
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Courtney E Collins
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Victor K Heh
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Holly E Baselice
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Scott A Strassels
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Heena P Santry
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA.
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Cohen C, Baird M, Koirola N, Kandrack R, Martsolf G. The Surgical and Anesthesia Workforce and Provision of Surgical Services in Rural Communities: A Mixed-Methods Examination. J Rural Health 2020; 37:45-54. [PMID: 32022951 DOI: 10.1111/jrh.12417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Rural-urban disparities in the surgical and anesthesia workforce exist. This mixed-methods study describes the distribution of the surgical and anesthesia workforce and qualitatively explores how such workforce and other factors influence rural hospitals' provision of surgical services. METHODS We calculated provider counts by county from the Area Health Resource File. Using American Hospital Association survey data, we sampled rural hospitals, stratified by critical access status and state policies. We conducted qualitative semistructured interviews with administrators at 16 hospitals and performed directed content analysis of factors influencing surgical services provision at rural hospitals. FINDINGS Within rural counties, 55.1% of counties had no surgeon, 81.2% had no anesthesiologist, and 58.1% had no Certified Registered Nurse Anesthetist (CRNA). Administrators reported that rural hospitals struggled to provide many surgical services given lack of subspecialty surgeons and adequate postsurgical care. Rural hospitals likely struggle to generate volumes necessary to support safe and profitable subspecialty surgery programs. Anesthesia services were not reported as a current limitation given that CRNAs in particular had strong, diverse skills sets and many hospitals allowed high CRNA autonomy. However, meeting anesthesia needs for emergency surgeries and 24-hour obstetrics posed significant challenges. CONCLUSIONS While rural hospitals reported meeting community needs for elective and noncomplex surgeries, rural hospitals continued to face significant challenges providing subspecialty surgeries, emergency surgeries, and 24-hour obstetrical services.
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Affiliation(s)
| | | | | | - Ryan Kandrack
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Grant Martsolf
- RAND Corporation, Pittsburgh, Pennsylvania.,Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
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Daniel VT, Rushing AP, Ingraham AM, Ricci KB, Paredes AZ, Diaz A, Ayturk MD, Baselice HE, Strassels SA, Santry HP. Association between operating room access and mortality for life-threatening general surgery emergencies. J Trauma Acute Care Surg 2019; 87:35-42. [PMID: 31242499 DOI: 10.1097/TA.0000000000002267] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Few diseases truly require emergency surgery today. We investigated the relationship between access to operating room (OR) and outcomes for patients with life-threatening emergency general surgery (LT-EGS) diseases at US hospitals. METHODS In 2015, we surveyed 2,811 US hospitals on EGS practices, including how OR access is assured (e.g., OR staffing, block time). There were 1,690 (60%) hospitals that responded. We anonymously linked survey data to 2015 Statewide Inpatient Sample data (17 states) using American Hospital Association identifiers. Adults admitted with life-threatening diagnoses (e.g., necrotizing fasciitis, perforated viscus) who underwent operative intervention the same calendar day as hospital admission were included. Primary outcome was in-hospital mortality. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to examine hospital-level OR access variables. RESULTS Overall, 3,620 patients were admitted with LT-EGS diseases. The median age was 63 years (interquartile range, 51-75), with half having three or more comorbidities (50%). Thirty-four percent had one or more major systemic complication, and 5% died. The majority got care at hospitals with less than 1 day of EGS block time but with policies to ensure emergency access to the OR. After adjusting for age, sex, race, insurance status, comorbidities, systemic complications, and surgical complications, we found that less presence of an in-house EGS surgeon, compared with around the clock, was associated with increased mortality (rarely/never in-house surgeon: odds ratio, 2.4; 95% confidence interval [CI],1.1-5.3; sometimes in-house surgeon: odds ratio, 1.6; 95% CI, 1.1-2.3). In addition, after controlling for other factors, on-call overnight recovery room nurse, compared with in-house, was associated with an increased mortality (odds ratio, 2.2; 95% CI, 1.5-3.1). CONCLUSION Round-the-clock availability of personnel, specifically emergency general surgeons and recovery room nurses, is associated with decreased mortality. These findings have implications for the creation of EGS patient triage criteria and Acute Care Surgery Centers of Excellence. LEVEL OF EVIDENCE Therapeutic, level III.
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Affiliation(s)
- Hayley Drew Germack
- Hayley Drew Germack is an assistant professor of acute and tertiary care at the University of Pittsburgh School of Nursing, in Pennsylvania
| | - Ryan Kandrack
- Ryan Kandrack is a PhD student in the Cecil G. Sheps Center for Health Services Research, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Grant R. Martsolf
- Grant R. Martsolf is a professor of acute and tertiary care at the University of Pittsburgh School of Nursing and an affiliated adjunct policy researcher at the RAND Corporation in Pittsburgh
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Nally DM, Sørensen J, Valentelyte G, Hammond L, McNamara D, Kavanagh DO, Mealy K. Volume and in-hospital mortality after emergency abdominal surgery: a national population-based study. BMJ Open 2019; 9:e032183. [PMID: 31678953 PMCID: PMC6830600 DOI: 10.1136/bmjopen-2019-032183] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES: Emergency abdominal surgery (EAS) refers to high-risk intra-abdominal surgical procedures undertaken for acute gastrointestinal pathology. The relationship between hospital or surgeon volume and mortality of patients undergoing EAS is poorly understood. This study examined this relationship at the national level. DESIGN: This is a national population-based study using a full administrative inpatient dataset (National Quality Assurance Improvement System) from publicly funded hospitals in Ireland. SETTING: 24 public hospitals providing EAS services. PARTICIPANTS AND INTERVENTIONS: Patients undergoing EAS as identified by primary procedure codes during the period 2014-2018. MAIN OUTCOME MEASURES: The main outcome measure was adjusted in-hospital mortality following EAS in publicly funded Irish hospitals. Mortality rates were adjusted for sex, age, admission source, Charlson Comorbidity Index, procedure complexity, organ system and primary diagnosis. Differences in overall, 7-day and 30-day in-hospital mortality for hospitals with low (<250), medium (250-449) and high (450+) volume and surgical teams with low (<30), medium (30-59) and high (60+) volume during the study period were also estimated. RESULTS: The study included 10 344 EAS episodes. 798 in-hospital deaths occurred, giving an overall in-hospital mortality rate of 77 per 1000 episodes. There was no statistically significant difference in adjusted mortality rate between low and high volume hospitals. Low volume surgical teams had a higher adjusted mortality rate (85.4 deaths/1000 episodes) compared with high volume teams (54.7 deaths/1000 episodes), a difference that persisted among low volume surgeons practising in high volume hospitals. CONCLUSION: Patients undergoing EAS managed by high volume surgeons have better survival outcomes. These findings contribute to the ongoing discussion regarding configuration of emergency surgery services and emphasise the need for effective clinical governance regarding observed variation in outcomes within and between institutions.
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Affiliation(s)
- Deirdre M Nally
- Department of Surgical Affairs, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Jan Sørensen
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Gintare Valentelyte
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Laura Hammond
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
- National Clinical Programme in Surgery (NCPS), Royal College of Surgeons (RCSI), Dublin, Ireland
| | - Deborah McNamara
- National Clinical Programme in Surgery (NCPS), Royal College of Surgeons (RCSI), Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgical Affairs, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Ken Mealy
- National Clinical Programme in Surgery (NCPS), Royal College of Surgeons (RCSI), Dublin, Ireland
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Ebner PJ, Ding L, Kim AW, Atay SM, Yao MJ, Toubat O, McFadden PM, Balekian AA, David EA. The Effect of Socioeconomic Status on Treatment and Mortality in Non-Small Cell Lung Cancer Patients. Ann Thorac Surg 2020; 109:225-32. [PMID: 31472134 DOI: 10.1016/j.athoracsur.2019.07.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/10/2019] [Accepted: 07/05/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Treatment decisions for patients with non-small cell lung cancer (NSCLC) are based on patient and tumor characteristics, including socioeconomic status (SES) factors. The objective was to assess the contribution of SES factors to treatment and outcomes among patients with stage I NSCLC. METHODS The National Cancer Database was queried for operable patients with stage I NSCLC. Patients were divided into three treatment groups: primary resection (ie, surgery only); nonstandard treatments consisting of chemotherapy with or without radiation; and no therapy. The SES of patients who made up the treatment groups was assessed, and the 5-year survival of all groups was analyzed. RESULTS The cohort included 69,168 patients with stage I NSCLC. Each of these patients had between zero and five SES risk factors. The factors associated with no surgery were low income, nonwhite race, low high school graduation rate, Medicaid or no insurance, rural residence, and distance less than 12.5 miles from treatment facility. Patients with several SES risk factors have linearly increasing odds of undergoing nonstandard treatments and quadratically increasing odds of having no therapy (for patients with five factors, to odds ratio 4.7; 95% confidence interval, 3.44 to 6.30). Surgery alone was associated with significantly longer 5-year survival (71.8%) compared with nonstandard treatments (22.7%) and no therapy (21.8%; P < .001). CONCLUSIONS Socioeconomic status factors increase the risk of undergoing guideline discordant therapy for stage I NSCLC. As the number of SES factors increases, the odds of no therapy rises quadratically whereas the odds of nonstandard treatments rises constantly. The surgery only group had significantly longer survival than the nonstandard treatment and no therapy groups.
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Oslock WM, Paredes AZ, Baselice HE, Rushing AP, Ingraham AM, Collins C, Ricci KB, Daniel VT, Diaz A, Heh VM, Strassels SA, Santry HP. Women surgeons and the emergence of acute care surgery programs. Am J Surg 2019; 218:803-808. [PMID: 31345501 DOI: 10.1016/j.amjsurg.2019.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/26/2019] [Accepted: 07/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND In parallel to women entering general surgery training, acute care surgery (ACS) has been developing as a team-based approach to emergency general surgery (EGS). We sought to examine predictors of women surgeons in EGS generally, and ACS particularly. METHODS From our national survey, we determined the proportion of women surgeons within EGS hospitals. We compared the proportion of women surgeons based on hospitals characteristics using chi-squared tests, then used regression models to measure odds of ACS relative to the proportion of women. RESULTS 779 (50.4%) hospitals had zero women surgeons. These hospitals were more likely non-ACS and non-teaching with <200 beds. ACS had a higher median proportion of women surgeons (17%) compared to non-ACS (0%). CONCLUSION Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by more recently trained surgeons. SUMMARY Using a national survey of Emergency General Surgery (EGS) hospitals, we sought to examine predictors of women surgeons in EGS generally, and acute care surgery (ACS) particularly. We found that 779 (50.4%) hospitals had zero women surgeons. Women were more likely to be among EGS surgeons at hospitals with ACS models. Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by a higher proportion of newly trained surgeons.
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Affiliation(s)
| | - Anghela Z Paredes
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Holly E Baselice
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Amy P Rushing
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | | | - Courtney Collins
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Kevin B Ricci
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Vijaya T Daniel
- University of Massachusetts Medical School, Department of Surgery, Worcester, MA, USA
| | - Adrian Diaz
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Victor M Heh
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Scott A Strassels
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Heena P Santry
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, OH, USA.
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Ricci KB, Rushing AP, Ingraham AM, Daniel VT, Paredes AZ, Diaz A, Heh VK, Baselice HE, Oslock WM, Strassels SA, Santry HP. The association between self-declared acute care surgery services and operating room access: Results from a national survey. J Trauma Acute Care Surg 2019; 87:898-906. [PMID: 31205221 DOI: 10.1097/ta.0000000000002394] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Timely access to the operating room (OR) for emergency general surgery (EGS) diseases is key to optimizing outcomes. We conducted a national survey on EGS structures and processes to examine if implementation of acute care surgery (ACS) would improve OR accessibility compared with a traditional general surgeon on call (GSOC) approach. METHODS We surveyed 2,811 acute care general hospitals in the United States capable of EGS care. The questionnaire included queries regarding structures and processes related to OR access and on the model of EGS care (ACS vs. GSOC). Associations between the EGS care model and structures and processes to ensure OR access were measured using univariate and multivariate models (adjusted for hospital characteristics). RESULTS Of 1,690 survey respondents (60.1%), 1,497 reported ACS or GSOC. 272 (18.2%) utilized an ACS model. The ACS hospitals were more likely to have more than 5 days of block time and a tiered system of booking urgent/emergent cases compared with GSOC hospitals (34.2% vs. 7.4% and 85.3% vs. 57.6%, respectively; all p values <0.001). Surgeons at ACS hospitals were more likely to be free of competing clinical duties, be in-house overnight, and cover at a single hospital overnight when covering EGS (40.1% vs. 4.7%, 64.7% vs. 25.6%, and 84.9% vs. 64.9%, respectively; all p values <0.001). The ACS hospitals were more likely to have overnight in-house scrub techs, OR nurses, and recovery room nurses (69.9% vs. 13.8%, 70.6% vs. 13.9%, and 45.6% vs. 5.4%, respectively; all p values <0.001). On multivariable analysis, ACS hospitals had higher odds of all structures and processes that would improve OR access. CONCLUSION The ACS implementation is associated with factors that may improve OR access. This finding has implications for potential expansion of EGS care models that ensure prompt OR access for the EGS diseases that warrant emergency surgery. LEVEL OF EVIDENCE Therapeutic, Level III.
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Affiliation(s)
- Kevin B Ricci
- From the Department of Surgery (K.B.R., A.P.R., A.Z.P., A.D., V.K.H., H.E.B., W.M.O., S.A.S., H.P.S.), Center for Surgical Health Assessment, Research and Policy (SHARP) (K.B.R., A.P.R., A.D., V.K.H., H.E.B., W.M.O., S.A.S., H.P.S.), Ohio State Wexner Medical Center, Columbus, Ohio; Department of Surgery (A.M.I.), University of Wisconsin, Madison, Wisconsin; Department of Surgery (V.T.D.), University of Massachusetts Medical School, Worcester, Massachusetts; and Ohio State University College of Medicine (W.M.O.), Columbus, Ohio
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Aranda-Narváez JM, Tallón-Aguilar L, López-Ruiz JA, Pareja-Ciuró F, Jover-Navalón JM, Turégano-Fuentes F, Navarro-Soto S, Ceballos-Esparragón J, Pérez-Díaz L. The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain. Cir Esp 2018; 97:3-10. [PMID: 30415793 DOI: 10.1016/j.ciresp.2018.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023]
Abstract
The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lola Pérez-Díaz
- Hospital General Universitario Gregorio Marañón, Madrid, España
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Daniel VT, Ayturk D, Kiefe CI, Santry HP. The current State of the acute care surgery workforce: A boots on the ground perspective. Am J Surg 2018; 216:1076-1081. [PMID: 30224074 DOI: 10.1016/j.amjsurg.2018.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 08/23/2018] [Accepted: 08/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Acute care surgery (ACS) was proposed to address a general surgery workforce crisis; however, the ACS workforce composition is unknown. A national survey was conducted to determine the differences in the emergency general surgery (EGS) workforce between ACS and non-ACS hospitals. METHODS The American Hospital Association (AHA) Annual Survey of Hospitals database was queried to identify acute care general hospitals. A hybrid mail/electronic survey was sent to 2811 acute care hospitals that met the inclusion criteria of hospitals that care for adult patients (≥18 years old) with an emergency room (ER), ≥ 1 operating room (OR), and 24-h ER access. Hospitals were queried on whether they utilized an ACS model. The workforce composition among ACS and non-ACS hospitals was evaluated using X2 tests, t tests, and Wilcoxon rank-sum tests. RESULTS Survey response was 60% (N = 1690). ACS hospitals had a higher proportion of emergency surgeons who were female (20% vs. 14%, p < 0.0001), newly-trained (17% vs 10%, p < 0.0001), critical care trained (78% vs. 31%, p < 0.0001), and who had an additional degree (35% vs. 13%, p < 0.0001). More ACS hospitals had 24/7 in-house OR nursing staff (72% vs. 15%, p < 0.0001) and ancillary staff. CONCLUSIONS ACS and non-ACS hospitals differ in their surgical workforce. It is clear that ACS hospitals have more human capital, which suggests that ACS hospitals may require more dedicated resources compared to non-ACS hospitals.
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Affiliation(s)
- Vijaya T Daniel
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Didem Ayturk
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Heena P Santry
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Daniel VT, Ingraham AM, Khubchandani JA, Ayturk D, Kiefe CI, Santry HP. Variations in the Delivery of Emergency General Surgery Care in the Era of Acute Care Surgery. Jt Comm J Qual Patient Saf 2018; 45:14-23. [PMID: 30093364 DOI: 10.1016/j.jcjq.2018.04.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/24/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Acute care surgery (ACS) was proposed to improve emergency general surgery (EGS) care; however, the extent of ACS model adoption in the United States is unknown. A national survey was conducted to ascertain factors associated with variations in EGS models of care, with particular focus on ACS use. METHODS A hybrid mail/electronic survey was sent in 2015 to 2,811 acute care hospitals with an emergency room and an operating room. If a respondent indicated that the approach to EGS was a dedicated clinical team whose scope encompasses EGS (± trauma, ± elective general surgery, ± burns), the hospital was considered an ACS hospital. RESULTS Survey response was 60.1% (n = 1,690); 272 (16.1%) of these hospitals reported having used an ACS model of care for EGS patients. Teaching status and general hospital practices (for example, interventional radiology available within one hour) were associated with ACS use. In bivariate analyses, ACS use was associated with many EGS-specific practices (40.1% of ACS hospitals freed their surgeons of daytime clinical responsibilities after operating overnight vs. 4.7% of general surgeon on call (GSOC) hospitals; p < 0.0001). CONCLUSION There are wide variations in EGS practices in the United States, with use of an ACS model of care being relatively low despite reported benefits of ACS models of care on EGS access, quality, and costs. Hospital factors associated with using ACS models are overall size and higher level of existing resources. These findings could be applied to the development of centers of excellence for EGS care.
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Coccolini F, Kluger Y, Ansaloni L, Moore EE, Coimbra R, Fraga GP, Kirkpatrick A, Peitzman A, Maier R, Baiocchi G, Agnoletti V, Gamberini E, Leppaniemi A, Ivatury R, Sugrue M, Sartelli M, Di Saverio S, Biffl W, Catena F. WSES worldwide emergency general surgery formation and evaluation project. World J Emerg Surg 2018; 13:13. [PMID: 29563962 PMCID: PMC5851068 DOI: 10.1186/s13017-018-0174-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 03/06/2018] [Indexed: 12/29/2022] Open
Abstract
Optimal management of emergency surgical patients represents one of the major health challenges worldwide. Emergency general surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital. EGS represents the easiest viable way to provide affordable and high-quality level of care to emergency surgical and trauma patients. It may result from the association of different physicians with other specialties in a cooperative model. The World Society of Emergency Surgery (WSES) has been working on the EGS organization and implementation since its foundation believing in the need of common benchmarks for training and educational programs throughout the world. This is a plea in different languages to all World Prime Ministers and Presidents to support the creation in all nations of an organized hub-spoke system for emergency general surgery to improve standards of care and to save lives.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, 47521 Cesena, Italy
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus Haifa, Haifa, Israel
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, 47521 Cesena, Italy
| | | | - Raul Coimbra
- Trauma Surgery, Riverside University Health System Medical Center, Riverside, CA USA
| | - Gustavo P. Fraga
- Faculdade de Ciências Médicas (FCM)—Unicamp Campinas, Campinas, SP Brazil
| | | | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Gianluca Baiocchi
- General and Emergency Surgery, Civili University Hospital, Brescia, Italy
| | | | | | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Salomone Di Saverio
- Trauma Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Walt Biffl
- Emergency and Trauma Surgery, Scripps Memorial Hospital, La Jolla, CA USA
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