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An Update on Acute Care Surgery
Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.
Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.
Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.
EMERGENCE OF ACUTE CARE SURGERY
Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels [1]. From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion [4]. This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity [5]. The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” [3]. Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity [3]. Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 [6]. An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages [1]. As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 [7].
At the center of these issues, described as “the perfect storm,” is the patient [8]. Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm [8]. In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery [9]. This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.
Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings, especially relative to the acute care surgery training paradigm. Whereas emergency general surgery refers to acute general surgical disorders, acute care surgery includes surgical critical care and the surgical management of acutely ill patients with a variety of conditions including trauma, burns, surgical critical care, or an acute general surgical condition. The challenges in caring for these patients include around-the-clock readiness for the provision of comprehensive care, the often constrained time for preoperative optimization of the patient, and the greater potential for intraoperative and postoperative complications due to the emergent nature of care. In managing these patients, acute care surgeons are fulfilling a huge patient care demand as the number of patients with acute surgical disorders is on the rise [4, 5]. And, each year, fewer general surgeons are available to participate in emergency room call to care for these patients. The general surgery workforce continues to shrink as each year more general surgeons retire and only about 25% of general surgery resident graduates choose to practice general surgery [11,12]. Hence, there is an increasing gap between the supply of general surgeons and the increasing numbers of patients with acute general surgical disorders. Another factor that contributes to the gap in supply and demand is the growing emphasis on minimally invasive techniques that have encouraged subspecialization. Minimally invasive surgery has also altered the operative experience of residents so that many general surgery graduates no longer feel comfortable taking care of patients with a broad range of general surgical conditions, especially those that are complex and time sensitive [9]. All of these factors support the continuous growing need for the well-trained acute care surgeon.
References
1. A growing crisis in patient access to emergency surgical care.
Bull. Am. Coll. Surg. 2006;91:8-19
2. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention. Department of Health and Human Services. Available at
http://www.cdc.gov/nchs/data/ad/ad358.pdf , accessed December 11, 2009.
4. Kellermann A. Crisis in the emergency department.
N. Engl. J. Med. 2006; 355:1300-3
5. American Hospital Association. Hospital Statistics 2006. Health Forum LLC, 2006.
6. https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf
7. On-call specialist coverage in U.S. Emergency Departments. American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available online at http://www.acep.org/workarea/DownloadAsset.aspx?id=33266
8. Rotondo MF. At the center of the “perfect storm”: the patient.
9. Jurkovich GJ et al: Acute care surgery: trauma, critical care, and emergency surgery. A report from the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.
10. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka.
J Am Coll Surg. 2006 Apr; 202(4):698-701 Epub 2006 Feb 21.
11. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model.
12. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.
J Am. Coll. Surg. 2008;206:782-8
Dr. Davis is professor of surgery, Vice Chairman of Clinical Affairs, chief of the Section of Trauma, Surgical Critical Care and Surgical Emergencies,Yale University School of Medicine; Trauma Medical Director and Surgical Director, Quality and Performance Improvement, Yale–New Haven Hospital, New Haven, Conn. Dr. Jurkovich is chief of surgery, Denver Health Medical Center.
Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.
Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.
Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.
EMERGENCE OF ACUTE CARE SURGERY
Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels [1]. From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion [4]. This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity [5]. The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” [3]. Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity [3]. Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 [6]. An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages [1]. As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 [7].
At the center of these issues, described as “the perfect storm,” is the patient [8]. Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm [8]. In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery [9]. This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.
Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings, especially relative to the acute care surgery training paradigm. Whereas emergency general surgery refers to acute general surgical disorders, acute care surgery includes surgical critical care and the surgical management of acutely ill patients with a variety of conditions including trauma, burns, surgical critical care, or an acute general surgical condition. The challenges in caring for these patients include around-the-clock readiness for the provision of comprehensive care, the often constrained time for preoperative optimization of the patient, and the greater potential for intraoperative and postoperative complications due to the emergent nature of care. In managing these patients, acute care surgeons are fulfilling a huge patient care demand as the number of patients with acute surgical disorders is on the rise [4, 5]. And, each year, fewer general surgeons are available to participate in emergency room call to care for these patients. The general surgery workforce continues to shrink as each year more general surgeons retire and only about 25% of general surgery resident graduates choose to practice general surgery [11,12]. Hence, there is an increasing gap between the supply of general surgeons and the increasing numbers of patients with acute general surgical disorders. Another factor that contributes to the gap in supply and demand is the growing emphasis on minimally invasive techniques that have encouraged subspecialization. Minimally invasive surgery has also altered the operative experience of residents so that many general surgery graduates no longer feel comfortable taking care of patients with a broad range of general surgical conditions, especially those that are complex and time sensitive [9]. All of these factors support the continuous growing need for the well-trained acute care surgeon.
References
1. A growing crisis in patient access to emergency surgical care.
Bull. Am. Coll. Surg. 2006;91:8-19
2. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention. Department of Health and Human Services. Available at
http://www.cdc.gov/nchs/data/ad/ad358.pdf , accessed December 11, 2009.
4. Kellermann A. Crisis in the emergency department.
N. Engl. J. Med. 2006; 355:1300-3
5. American Hospital Association. Hospital Statistics 2006. Health Forum LLC, 2006.
6. https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf
7. On-call specialist coverage in U.S. Emergency Departments. American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available online at http://www.acep.org/workarea/DownloadAsset.aspx?id=33266
8. Rotondo MF. At the center of the “perfect storm”: the patient.
9. Jurkovich GJ et al: Acute care surgery: trauma, critical care, and emergency surgery. A report from the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.
10. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka.
J Am Coll Surg. 2006 Apr; 202(4):698-701 Epub 2006 Feb 21.
11. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model.
12. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.
J Am. Coll. Surg. 2008;206:782-8
Dr. Davis is professor of surgery, Vice Chairman of Clinical Affairs, chief of the Section of Trauma, Surgical Critical Care and Surgical Emergencies,Yale University School of Medicine; Trauma Medical Director and Surgical Director, Quality and Performance Improvement, Yale–New Haven Hospital, New Haven, Conn. Dr. Jurkovich is chief of surgery, Denver Health Medical Center.
Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.
Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.
Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.
EMERGENCE OF ACUTE CARE SURGERY
Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels [1]. From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion [4]. This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity [5]. The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” [3]. Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity [3]. Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 [6]. An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages [1]. As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 [7].
At the center of these issues, described as “the perfect storm,” is the patient [8]. Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm [8]. In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery [9]. This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.
Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings, especially relative to the acute care surgery training paradigm. Whereas emergency general surgery refers to acute general surgical disorders, acute care surgery includes surgical critical care and the surgical management of acutely ill patients with a variety of conditions including trauma, burns, surgical critical care, or an acute general surgical condition. The challenges in caring for these patients include around-the-clock readiness for the provision of comprehensive care, the often constrained time for preoperative optimization of the patient, and the greater potential for intraoperative and postoperative complications due to the emergent nature of care. In managing these patients, acute care surgeons are fulfilling a huge patient care demand as the number of patients with acute surgical disorders is on the rise [4, 5]. And, each year, fewer general surgeons are available to participate in emergency room call to care for these patients. The general surgery workforce continues to shrink as each year more general surgeons retire and only about 25% of general surgery resident graduates choose to practice general surgery [11,12]. Hence, there is an increasing gap between the supply of general surgeons and the increasing numbers of patients with acute general surgical disorders. Another factor that contributes to the gap in supply and demand is the growing emphasis on minimally invasive techniques that have encouraged subspecialization. Minimally invasive surgery has also altered the operative experience of residents so that many general surgery graduates no longer feel comfortable taking care of patients with a broad range of general surgical conditions, especially those that are complex and time sensitive [9]. All of these factors support the continuous growing need for the well-trained acute care surgeon.
References
1. A growing crisis in patient access to emergency surgical care.
Bull. Am. Coll. Surg. 2006;91:8-19
2. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention. Department of Health and Human Services. Available at
http://www.cdc.gov/nchs/data/ad/ad358.pdf , accessed December 11, 2009.
4. Kellermann A. Crisis in the emergency department.
N. Engl. J. Med. 2006; 355:1300-3
5. American Hospital Association. Hospital Statistics 2006. Health Forum LLC, 2006.
6. https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf
7. On-call specialist coverage in U.S. Emergency Departments. American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available online at http://www.acep.org/workarea/DownloadAsset.aspx?id=33266
8. Rotondo MF. At the center of the “perfect storm”: the patient.
9. Jurkovich GJ et al: Acute care surgery: trauma, critical care, and emergency surgery. A report from the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.
10. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka.
J Am Coll Surg. 2006 Apr; 202(4):698-701 Epub 2006 Feb 21.
11. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model.
12. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.
J Am. Coll. Surg. 2008;206:782-8
Dr. Davis is professor of surgery, Vice Chairman of Clinical Affairs, chief of the Section of Trauma, Surgical Critical Care and Surgical Emergencies,Yale University School of Medicine; Trauma Medical Director and Surgical Director, Quality and Performance Improvement, Yale–New Haven Hospital, New Haven, Conn. Dr. Jurkovich is chief of surgery, Denver Health Medical Center.
Regionalized health care and the trauma system model
Editor’s Note: This editorial is based on the Presidential Address given by Dr. Jurkovich at the 2012 annual meeting of the Western Surgical Association.
Regionalization of health care is part of the larger dynamic of change in medicine that includes an aging population, financing reform, and generational identity issues of physicians in training and future providers of care. Trauma systems provide a model for effective regionalized care, and in this context, I propose a network of national acute care surgery hospitals built on this model. But there are lessons that can be learned from 35 years of trauma systems development and implementation that can be applied to a network of national acute care surgery hospitals (J. Am. Coll. Surg. 2012;215:1-11).
The problem of lack of emergency surgical resources has been noted since the beginning of the 21st century, and has received considerable attention from a wide variety of public and private organizations and government agencies. A cover story of U.S. News and World Report in 2001 was entitled "Crisis in the ER." The influential Institute of Medicine (IOM) three-volume report in 2009 entitled "Future of Emergency Care" noted that hospital-based emergency care was as the breaking point, with overcrowding of emergency departments (ED), boarding of patients in the ED, with ambulance diversion and uncompensated care being the most pressing problems. The Robert Wood Johnson foundation report authored by Dr. Mitesh B. Rao and his colleagues in 2011 highlighted the shortage of surgeons who take emergency call and suggested that "three-quarters of the nations’ emergency departments do not have enough on-call coverage by surgical specialists to meet the demand for round-the-clock specialty care."
One of the key solutions suggested in the IOM report was to develop regionalized on-call specialty care services. The concept is that if hospitals cannot find willing (or able) surgical coverage for certain surgical urgencies or emergencies, then the patients should be sent to regionalized centers of care that can provide these services. The burden on the patient is significant: The patient may have to travel some distance to receive health care. The burden on the receiving hospital is also significant: The patients often are the most challenging and underfunded in medicine. The burden on the profession of surgery is also significant, if often overlooked: a further erosion of the perception of our profession from one concerned primarily with the sick and suffering and to a perception that specialty surgeons are more concerned about lifestyle and personal gain. Nonetheless, this does appear to be the best model for the future of surgical care. The purpose of regionalization of care is to consolidate complex and high-technology medicine into regional centers with adequate surgeons in all specialties, in the hope that this will ensure quality and cost-effective care. It is an opportunity for surgical leadership to become involved in this dramatic change in medicine.
Regionalization: The trauma system model
In 1976, the American College of Surgeons Committee on Trauma published the first version of "The optimal resources for a hospital." The eighth version will be released shortly. This document is the authoritative source on trauma center function. Initially developed to serve as a guideline for what resources were required for a hospital trauma center, a name change in 1990 to "Resources for Optimal Care of the Injured Patients" expanded the implications and reach of these guidelines (J. Trauma 1998;47(3 Suppl.):S1).
What makes trauma center care better? In a study of 31 academic Level 1 trauma centers, the higher volume trauma centers (more than 650 major trauma admissions per year) had improved outcomes, particularly for the sickest patients (JAMA 2001;285:1164-71).
Improved critical care also seems partially responsible for better outcomes at trauma centers. The ability of trauma centers to salvage patients with complications or severe shock and injury appears to be a defining characteristic of those centers with the better outcomes. In addition, trauma intensive care units that are "closed" and staffed by surgical critical care surgeons achieve the best results (J. Trauma 2011;70:575-82; Arch. Surg. 2003;138:47-51;discussion 51; J. Trauma 2006;60:773-83;discussion 783-4; Ann. Surg. 2006;244:545-54).
The reasons trauma centers have improved outcomes appears to be multifactorial, injury-pattern dependent, and not entirely understood. It appears it is not just the hospital designation that makes the difference, but the design and effectiveness of system integration that is equally important.
These examples emphasize the point that a series of activities and actions is required for regionalizing care, not simply forcing a specific population of patients into one hospital. The model trauma system plan written by the HRSA in 1992, with help from the ACS Committee on Trauma and CDC continues to serve as the benchmark for trauma system design (Health Resources and Services Administration. A 2002 national assessment of state trauma system development, emergency medical services resources, and disaster readiness for mass casualty events. Washington: U.S. Department of Health and Human Services, 2003). This plan is based on work and definitions first described by West et al., and modified by Bazzoli et al. (JAMA 1995;273:395-401; JAMA 1988;259:3597-600).
The essential components of a trauma system are designating hospitals as having a specific range of resources, proscribing prehospital triage protocols that allow the selective bypassing of nontrauma centers or lower levels of care, requiring inter-facility transfer agreements, developing quality assurance programs with teeth and the ability to impact change, ensuring regional or state-wide coverage, and importantly, limiting the number of centers based on need for patient care. These steps are rarely accomplished voluntarily, but require government regulations that also provide financial incentives to cover the large number of uninsured trauma patients.
The effectiveness of this approach to regionalized care is remarkable. A recent paper looked at 2.7 million trauma patients from the National Inpatient Sampling (NIS) data between 1995 and 2003 (JAMA 1988;259:3597-600). This paper defined major trauma as patients with a mortality risk of 10% or greater based on injury severity as calculated using ICD-9–based Injury Severity Score (ICISS). They defined high-volume trauma centers as those that treat 915 or more major trauma patients a year. In the United States, only 7% of hospitals meet this threshold, yet they provide 60% of the total major trauma volume care in this country (Figure 7). That’s effective regionalization. That’s an effective concentration of resources that saves lives.
National Trauma and Acute Care Surgery Center Network: A Proposal
I would like to propose the creation of a national network of high-volume, high-acuity trauma and acute care surgery medical centers. Let’s call this the National Trauma and Acute Care Surgery Centers Network (NTACS Network). There are currently about 200 Level 1 trauma centers in the United States, with 107 verified by the American College of Surgeons (ACS) and the rest verified by state agencies using similar (but not exactly the same) criteria. The ideal population volume per Level 1 trauma center is under discussion, but probably a minimum of 1-3 million people per Level 1 trauma center is most appropriate. Any fewer and the volume of cases is diluted and efficiency of concentration and expertise is lost. As the population of the United States is about 300 million people, the ideal number of trauma centers would be between 100 and 300. I tend to favor fewer Level 1 centers, and a greater concentration of the most difficult cases and expertise. So, for the purposes of this proposal, let’s say one NTACS Center for every 2.5 million people, meaning a network of 120 such centers across the country would be required. This density of trauma centers is readily met (and often exceeded) in urban and suburban environments, but is more difficult to achieve in the rural Western states.
Staffing and resources for this NTACS Network would be consistent with what the ACS requires for verification of Level 1 trauma centers. From the standpoint of surgical coverage, a cadre of general surgeons with specific training and expertise in trauma, surgical critical care, and emergency general surgery – the acute care surgeon model – would be ideal coverage for this type of center (J. Trauma 2005;58:614-6; Surgery 2007;141:293-6).
Eight to ten such surgeons, with resident and/or mid-level providers, would provide coverage for surgical critical care, emergency general surgery, trauma surgery, research and education, and administrative duties, implying a need for 960-1,200 such surgeons. These surgeons would provide primary surgical care for trauma, critical care, and emergency and elective general surgery, with 1 night a week in house on call, and time for research and administration, and adequate vacation and sick-leave coverage.
A strategy for interesting the new generation of surgeons in this national network of trauma and acute care surgical centers could focus on incentives to draw the best and brightest. Loan forgiveness programs for medical school education could be applied to surgeons working in such centers. Volunteers could be recruited, perhaps establishing an AmeriCorps for physicians. With adequate manpower, fixed time off, set schedules, and protected time after night coverage and for academic activities would be easier to arrange. Fixed minimum incomes with volume and work performance incentives could be applied. Malpractice limits, similar to the protection state and federal agencies enjoy, could be applied. Facilities participating in the network could readily become academic centers of excellence. The academic productivity and clinical research material from a well-organized network of such facilities would be phenomenal, and serve as the model for multicenter trials and studies of a wide array of interventions, procedures, and practices. Standardization of care would be much easier to obtain, as would dissemination of new information and practices.
The cost for this national network of trauma and acute care surgery centers can be estimated, if only on the back of a napkin at this point. If each hospital had about 300-400 beds, and an estimated annual operating budget of $600 million, the total operating costs for 120 such centers would be $72 billion. If one-half of that money came from third-party health care insurance sources, the federal costs would be about $36 billion, certainly less than the $50 billion proposed in the 2012 Veterans Affairs budget for direct medical care (Office of Management and Budget, Fiscal Year 2012 Budget of the U.S. Government. Washington: USGPO, 2012. p. 137-49). These figures can be compared with the wide range of public dollars spent by communities to provide safety-net coverage. For example, the city and county of Denver budgets about $27 million annually to Denver Health, while the city of San Francisco supports San Francisco General with about $38 million annually from their general fund.
How close are we to having the manpower to meet the needs of such a network of hospitals? Over the past 4 years, 10%-12% of the current 1,100 graduates of general surgery training programs go on to do a surgical critical care residency. That’s actually more than or equal to vascular, pediatrics, hand, or thoracic surgery specialty training. In 2009 there were 2,583 surgeons who take their board in surgical critical care, and 1,204 of them have been recertified at least once (J. Trauma 2010;69:1619-3).
In addition, there is the ongoing development of acute care surgery training programs, spearheaded by the American Association for the Surgery of Trauma, with a goal of 20-30 such training programs. (J. Trauma 2005;58:614-6; J. Trauma 2007;62:553-6; J. Trauma Acute Care Surg. 2012;72:4-10; J. Trauma 2010;68:753-60).
So we have the manpower, and we have a great distribution of trauma centers across this country, with authoritative legislation in most of the states. A total of 83% of the population is within 1 hour of trauma center care by ambulance or helicopter (JAMA 2005;293:2626-33).
Western rural states have the unsolved problem of adequate access to trauma center care, primarily because the population density cannot support such highly specialized centers. But with improved organization of regionalized transportation, this issue could be addressed, and these patients and resources concentrated. Urban America has a different problem in some locations, which is the oversubscribing of trauma centers because of ego, greed, lack of cooperation, and a presumed drive for prestige. This problem could be solved with legislation and changes in funding for trauma and acute care.
Trauma care systems are a model for regionalization of all time-sensitive illnesses, not just trauma, and not just surgical issues; the integrated trauma system model can be the future of regionalization of all health care.
Dr. Jurkovich, an ACS Fellow, is chief of surgery at Denver Health, and vice chairman of surgery, University of Colorado in Denver.
Editor’s Note: This editorial is based on the Presidential Address given by Dr. Jurkovich at the 2012 annual meeting of the Western Surgical Association.
Regionalization of health care is part of the larger dynamic of change in medicine that includes an aging population, financing reform, and generational identity issues of physicians in training and future providers of care. Trauma systems provide a model for effective regionalized care, and in this context, I propose a network of national acute care surgery hospitals built on this model. But there are lessons that can be learned from 35 years of trauma systems development and implementation that can be applied to a network of national acute care surgery hospitals (J. Am. Coll. Surg. 2012;215:1-11).
The problem of lack of emergency surgical resources has been noted since the beginning of the 21st century, and has received considerable attention from a wide variety of public and private organizations and government agencies. A cover story of U.S. News and World Report in 2001 was entitled "Crisis in the ER." The influential Institute of Medicine (IOM) three-volume report in 2009 entitled "Future of Emergency Care" noted that hospital-based emergency care was as the breaking point, with overcrowding of emergency departments (ED), boarding of patients in the ED, with ambulance diversion and uncompensated care being the most pressing problems. The Robert Wood Johnson foundation report authored by Dr. Mitesh B. Rao and his colleagues in 2011 highlighted the shortage of surgeons who take emergency call and suggested that "three-quarters of the nations’ emergency departments do not have enough on-call coverage by surgical specialists to meet the demand for round-the-clock specialty care."
One of the key solutions suggested in the IOM report was to develop regionalized on-call specialty care services. The concept is that if hospitals cannot find willing (or able) surgical coverage for certain surgical urgencies or emergencies, then the patients should be sent to regionalized centers of care that can provide these services. The burden on the patient is significant: The patient may have to travel some distance to receive health care. The burden on the receiving hospital is also significant: The patients often are the most challenging and underfunded in medicine. The burden on the profession of surgery is also significant, if often overlooked: a further erosion of the perception of our profession from one concerned primarily with the sick and suffering and to a perception that specialty surgeons are more concerned about lifestyle and personal gain. Nonetheless, this does appear to be the best model for the future of surgical care. The purpose of regionalization of care is to consolidate complex and high-technology medicine into regional centers with adequate surgeons in all specialties, in the hope that this will ensure quality and cost-effective care. It is an opportunity for surgical leadership to become involved in this dramatic change in medicine.
Regionalization: The trauma system model
In 1976, the American College of Surgeons Committee on Trauma published the first version of "The optimal resources for a hospital." The eighth version will be released shortly. This document is the authoritative source on trauma center function. Initially developed to serve as a guideline for what resources were required for a hospital trauma center, a name change in 1990 to "Resources for Optimal Care of the Injured Patients" expanded the implications and reach of these guidelines (J. Trauma 1998;47(3 Suppl.):S1).
What makes trauma center care better? In a study of 31 academic Level 1 trauma centers, the higher volume trauma centers (more than 650 major trauma admissions per year) had improved outcomes, particularly for the sickest patients (JAMA 2001;285:1164-71).
Improved critical care also seems partially responsible for better outcomes at trauma centers. The ability of trauma centers to salvage patients with complications or severe shock and injury appears to be a defining characteristic of those centers with the better outcomes. In addition, trauma intensive care units that are "closed" and staffed by surgical critical care surgeons achieve the best results (J. Trauma 2011;70:575-82; Arch. Surg. 2003;138:47-51;discussion 51; J. Trauma 2006;60:773-83;discussion 783-4; Ann. Surg. 2006;244:545-54).
The reasons trauma centers have improved outcomes appears to be multifactorial, injury-pattern dependent, and not entirely understood. It appears it is not just the hospital designation that makes the difference, but the design and effectiveness of system integration that is equally important.
These examples emphasize the point that a series of activities and actions is required for regionalizing care, not simply forcing a specific population of patients into one hospital. The model trauma system plan written by the HRSA in 1992, with help from the ACS Committee on Trauma and CDC continues to serve as the benchmark for trauma system design (Health Resources and Services Administration. A 2002 national assessment of state trauma system development, emergency medical services resources, and disaster readiness for mass casualty events. Washington: U.S. Department of Health and Human Services, 2003). This plan is based on work and definitions first described by West et al., and modified by Bazzoli et al. (JAMA 1995;273:395-401; JAMA 1988;259:3597-600).
The essential components of a trauma system are designating hospitals as having a specific range of resources, proscribing prehospital triage protocols that allow the selective bypassing of nontrauma centers or lower levels of care, requiring inter-facility transfer agreements, developing quality assurance programs with teeth and the ability to impact change, ensuring regional or state-wide coverage, and importantly, limiting the number of centers based on need for patient care. These steps are rarely accomplished voluntarily, but require government regulations that also provide financial incentives to cover the large number of uninsured trauma patients.
The effectiveness of this approach to regionalized care is remarkable. A recent paper looked at 2.7 million trauma patients from the National Inpatient Sampling (NIS) data between 1995 and 2003 (JAMA 1988;259:3597-600). This paper defined major trauma as patients with a mortality risk of 10% or greater based on injury severity as calculated using ICD-9–based Injury Severity Score (ICISS). They defined high-volume trauma centers as those that treat 915 or more major trauma patients a year. In the United States, only 7% of hospitals meet this threshold, yet they provide 60% of the total major trauma volume care in this country (Figure 7). That’s effective regionalization. That’s an effective concentration of resources that saves lives.
National Trauma and Acute Care Surgery Center Network: A Proposal
I would like to propose the creation of a national network of high-volume, high-acuity trauma and acute care surgery medical centers. Let’s call this the National Trauma and Acute Care Surgery Centers Network (NTACS Network). There are currently about 200 Level 1 trauma centers in the United States, with 107 verified by the American College of Surgeons (ACS) and the rest verified by state agencies using similar (but not exactly the same) criteria. The ideal population volume per Level 1 trauma center is under discussion, but probably a minimum of 1-3 million people per Level 1 trauma center is most appropriate. Any fewer and the volume of cases is diluted and efficiency of concentration and expertise is lost. As the population of the United States is about 300 million people, the ideal number of trauma centers would be between 100 and 300. I tend to favor fewer Level 1 centers, and a greater concentration of the most difficult cases and expertise. So, for the purposes of this proposal, let’s say one NTACS Center for every 2.5 million people, meaning a network of 120 such centers across the country would be required. This density of trauma centers is readily met (and often exceeded) in urban and suburban environments, but is more difficult to achieve in the rural Western states.
Staffing and resources for this NTACS Network would be consistent with what the ACS requires for verification of Level 1 trauma centers. From the standpoint of surgical coverage, a cadre of general surgeons with specific training and expertise in trauma, surgical critical care, and emergency general surgery – the acute care surgeon model – would be ideal coverage for this type of center (J. Trauma 2005;58:614-6; Surgery 2007;141:293-6).
Eight to ten such surgeons, with resident and/or mid-level providers, would provide coverage for surgical critical care, emergency general surgery, trauma surgery, research and education, and administrative duties, implying a need for 960-1,200 such surgeons. These surgeons would provide primary surgical care for trauma, critical care, and emergency and elective general surgery, with 1 night a week in house on call, and time for research and administration, and adequate vacation and sick-leave coverage.
A strategy for interesting the new generation of surgeons in this national network of trauma and acute care surgical centers could focus on incentives to draw the best and brightest. Loan forgiveness programs for medical school education could be applied to surgeons working in such centers. Volunteers could be recruited, perhaps establishing an AmeriCorps for physicians. With adequate manpower, fixed time off, set schedules, and protected time after night coverage and for academic activities would be easier to arrange. Fixed minimum incomes with volume and work performance incentives could be applied. Malpractice limits, similar to the protection state and federal agencies enjoy, could be applied. Facilities participating in the network could readily become academic centers of excellence. The academic productivity and clinical research material from a well-organized network of such facilities would be phenomenal, and serve as the model for multicenter trials and studies of a wide array of interventions, procedures, and practices. Standardization of care would be much easier to obtain, as would dissemination of new information and practices.
The cost for this national network of trauma and acute care surgery centers can be estimated, if only on the back of a napkin at this point. If each hospital had about 300-400 beds, and an estimated annual operating budget of $600 million, the total operating costs for 120 such centers would be $72 billion. If one-half of that money came from third-party health care insurance sources, the federal costs would be about $36 billion, certainly less than the $50 billion proposed in the 2012 Veterans Affairs budget for direct medical care (Office of Management and Budget, Fiscal Year 2012 Budget of the U.S. Government. Washington: USGPO, 2012. p. 137-49). These figures can be compared with the wide range of public dollars spent by communities to provide safety-net coverage. For example, the city and county of Denver budgets about $27 million annually to Denver Health, while the city of San Francisco supports San Francisco General with about $38 million annually from their general fund.
How close are we to having the manpower to meet the needs of such a network of hospitals? Over the past 4 years, 10%-12% of the current 1,100 graduates of general surgery training programs go on to do a surgical critical care residency. That’s actually more than or equal to vascular, pediatrics, hand, or thoracic surgery specialty training. In 2009 there were 2,583 surgeons who take their board in surgical critical care, and 1,204 of them have been recertified at least once (J. Trauma 2010;69:1619-3).
In addition, there is the ongoing development of acute care surgery training programs, spearheaded by the American Association for the Surgery of Trauma, with a goal of 20-30 such training programs. (J. Trauma 2005;58:614-6; J. Trauma 2007;62:553-6; J. Trauma Acute Care Surg. 2012;72:4-10; J. Trauma 2010;68:753-60).
So we have the manpower, and we have a great distribution of trauma centers across this country, with authoritative legislation in most of the states. A total of 83% of the population is within 1 hour of trauma center care by ambulance or helicopter (JAMA 2005;293:2626-33).
Western rural states have the unsolved problem of adequate access to trauma center care, primarily because the population density cannot support such highly specialized centers. But with improved organization of regionalized transportation, this issue could be addressed, and these patients and resources concentrated. Urban America has a different problem in some locations, which is the oversubscribing of trauma centers because of ego, greed, lack of cooperation, and a presumed drive for prestige. This problem could be solved with legislation and changes in funding for trauma and acute care.
Trauma care systems are a model for regionalization of all time-sensitive illnesses, not just trauma, and not just surgical issues; the integrated trauma system model can be the future of regionalization of all health care.
Dr. Jurkovich, an ACS Fellow, is chief of surgery at Denver Health, and vice chairman of surgery, University of Colorado in Denver.
Editor’s Note: This editorial is based on the Presidential Address given by Dr. Jurkovich at the 2012 annual meeting of the Western Surgical Association.
Regionalization of health care is part of the larger dynamic of change in medicine that includes an aging population, financing reform, and generational identity issues of physicians in training and future providers of care. Trauma systems provide a model for effective regionalized care, and in this context, I propose a network of national acute care surgery hospitals built on this model. But there are lessons that can be learned from 35 years of trauma systems development and implementation that can be applied to a network of national acute care surgery hospitals (J. Am. Coll. Surg. 2012;215:1-11).
The problem of lack of emergency surgical resources has been noted since the beginning of the 21st century, and has received considerable attention from a wide variety of public and private organizations and government agencies. A cover story of U.S. News and World Report in 2001 was entitled "Crisis in the ER." The influential Institute of Medicine (IOM) three-volume report in 2009 entitled "Future of Emergency Care" noted that hospital-based emergency care was as the breaking point, with overcrowding of emergency departments (ED), boarding of patients in the ED, with ambulance diversion and uncompensated care being the most pressing problems. The Robert Wood Johnson foundation report authored by Dr. Mitesh B. Rao and his colleagues in 2011 highlighted the shortage of surgeons who take emergency call and suggested that "three-quarters of the nations’ emergency departments do not have enough on-call coverage by surgical specialists to meet the demand for round-the-clock specialty care."
One of the key solutions suggested in the IOM report was to develop regionalized on-call specialty care services. The concept is that if hospitals cannot find willing (or able) surgical coverage for certain surgical urgencies or emergencies, then the patients should be sent to regionalized centers of care that can provide these services. The burden on the patient is significant: The patient may have to travel some distance to receive health care. The burden on the receiving hospital is also significant: The patients often are the most challenging and underfunded in medicine. The burden on the profession of surgery is also significant, if often overlooked: a further erosion of the perception of our profession from one concerned primarily with the sick and suffering and to a perception that specialty surgeons are more concerned about lifestyle and personal gain. Nonetheless, this does appear to be the best model for the future of surgical care. The purpose of regionalization of care is to consolidate complex and high-technology medicine into regional centers with adequate surgeons in all specialties, in the hope that this will ensure quality and cost-effective care. It is an opportunity for surgical leadership to become involved in this dramatic change in medicine.
Regionalization: The trauma system model
In 1976, the American College of Surgeons Committee on Trauma published the first version of "The optimal resources for a hospital." The eighth version will be released shortly. This document is the authoritative source on trauma center function. Initially developed to serve as a guideline for what resources were required for a hospital trauma center, a name change in 1990 to "Resources for Optimal Care of the Injured Patients" expanded the implications and reach of these guidelines (J. Trauma 1998;47(3 Suppl.):S1).
What makes trauma center care better? In a study of 31 academic Level 1 trauma centers, the higher volume trauma centers (more than 650 major trauma admissions per year) had improved outcomes, particularly for the sickest patients (JAMA 2001;285:1164-71).
Improved critical care also seems partially responsible for better outcomes at trauma centers. The ability of trauma centers to salvage patients with complications or severe shock and injury appears to be a defining characteristic of those centers with the better outcomes. In addition, trauma intensive care units that are "closed" and staffed by surgical critical care surgeons achieve the best results (J. Trauma 2011;70:575-82; Arch. Surg. 2003;138:47-51;discussion 51; J. Trauma 2006;60:773-83;discussion 783-4; Ann. Surg. 2006;244:545-54).
The reasons trauma centers have improved outcomes appears to be multifactorial, injury-pattern dependent, and not entirely understood. It appears it is not just the hospital designation that makes the difference, but the design and effectiveness of system integration that is equally important.
These examples emphasize the point that a series of activities and actions is required for regionalizing care, not simply forcing a specific population of patients into one hospital. The model trauma system plan written by the HRSA in 1992, with help from the ACS Committee on Trauma and CDC continues to serve as the benchmark for trauma system design (Health Resources and Services Administration. A 2002 national assessment of state trauma system development, emergency medical services resources, and disaster readiness for mass casualty events. Washington: U.S. Department of Health and Human Services, 2003). This plan is based on work and definitions first described by West et al., and modified by Bazzoli et al. (JAMA 1995;273:395-401; JAMA 1988;259:3597-600).
The essential components of a trauma system are designating hospitals as having a specific range of resources, proscribing prehospital triage protocols that allow the selective bypassing of nontrauma centers or lower levels of care, requiring inter-facility transfer agreements, developing quality assurance programs with teeth and the ability to impact change, ensuring regional or state-wide coverage, and importantly, limiting the number of centers based on need for patient care. These steps are rarely accomplished voluntarily, but require government regulations that also provide financial incentives to cover the large number of uninsured trauma patients.
The effectiveness of this approach to regionalized care is remarkable. A recent paper looked at 2.7 million trauma patients from the National Inpatient Sampling (NIS) data between 1995 and 2003 (JAMA 1988;259:3597-600). This paper defined major trauma as patients with a mortality risk of 10% or greater based on injury severity as calculated using ICD-9–based Injury Severity Score (ICISS). They defined high-volume trauma centers as those that treat 915 or more major trauma patients a year. In the United States, only 7% of hospitals meet this threshold, yet they provide 60% of the total major trauma volume care in this country (Figure 7). That’s effective regionalization. That’s an effective concentration of resources that saves lives.
National Trauma and Acute Care Surgery Center Network: A Proposal
I would like to propose the creation of a national network of high-volume, high-acuity trauma and acute care surgery medical centers. Let’s call this the National Trauma and Acute Care Surgery Centers Network (NTACS Network). There are currently about 200 Level 1 trauma centers in the United States, with 107 verified by the American College of Surgeons (ACS) and the rest verified by state agencies using similar (but not exactly the same) criteria. The ideal population volume per Level 1 trauma center is under discussion, but probably a minimum of 1-3 million people per Level 1 trauma center is most appropriate. Any fewer and the volume of cases is diluted and efficiency of concentration and expertise is lost. As the population of the United States is about 300 million people, the ideal number of trauma centers would be between 100 and 300. I tend to favor fewer Level 1 centers, and a greater concentration of the most difficult cases and expertise. So, for the purposes of this proposal, let’s say one NTACS Center for every 2.5 million people, meaning a network of 120 such centers across the country would be required. This density of trauma centers is readily met (and often exceeded) in urban and suburban environments, but is more difficult to achieve in the rural Western states.
Staffing and resources for this NTACS Network would be consistent with what the ACS requires for verification of Level 1 trauma centers. From the standpoint of surgical coverage, a cadre of general surgeons with specific training and expertise in trauma, surgical critical care, and emergency general surgery – the acute care surgeon model – would be ideal coverage for this type of center (J. Trauma 2005;58:614-6; Surgery 2007;141:293-6).
Eight to ten such surgeons, with resident and/or mid-level providers, would provide coverage for surgical critical care, emergency general surgery, trauma surgery, research and education, and administrative duties, implying a need for 960-1,200 such surgeons. These surgeons would provide primary surgical care for trauma, critical care, and emergency and elective general surgery, with 1 night a week in house on call, and time for research and administration, and adequate vacation and sick-leave coverage.
A strategy for interesting the new generation of surgeons in this national network of trauma and acute care surgical centers could focus on incentives to draw the best and brightest. Loan forgiveness programs for medical school education could be applied to surgeons working in such centers. Volunteers could be recruited, perhaps establishing an AmeriCorps for physicians. With adequate manpower, fixed time off, set schedules, and protected time after night coverage and for academic activities would be easier to arrange. Fixed minimum incomes with volume and work performance incentives could be applied. Malpractice limits, similar to the protection state and federal agencies enjoy, could be applied. Facilities participating in the network could readily become academic centers of excellence. The academic productivity and clinical research material from a well-organized network of such facilities would be phenomenal, and serve as the model for multicenter trials and studies of a wide array of interventions, procedures, and practices. Standardization of care would be much easier to obtain, as would dissemination of new information and practices.
The cost for this national network of trauma and acute care surgery centers can be estimated, if only on the back of a napkin at this point. If each hospital had about 300-400 beds, and an estimated annual operating budget of $600 million, the total operating costs for 120 such centers would be $72 billion. If one-half of that money came from third-party health care insurance sources, the federal costs would be about $36 billion, certainly less than the $50 billion proposed in the 2012 Veterans Affairs budget for direct medical care (Office of Management and Budget, Fiscal Year 2012 Budget of the U.S. Government. Washington: USGPO, 2012. p. 137-49). These figures can be compared with the wide range of public dollars spent by communities to provide safety-net coverage. For example, the city and county of Denver budgets about $27 million annually to Denver Health, while the city of San Francisco supports San Francisco General with about $38 million annually from their general fund.
How close are we to having the manpower to meet the needs of such a network of hospitals? Over the past 4 years, 10%-12% of the current 1,100 graduates of general surgery training programs go on to do a surgical critical care residency. That’s actually more than or equal to vascular, pediatrics, hand, or thoracic surgery specialty training. In 2009 there were 2,583 surgeons who take their board in surgical critical care, and 1,204 of them have been recertified at least once (J. Trauma 2010;69:1619-3).
In addition, there is the ongoing development of acute care surgery training programs, spearheaded by the American Association for the Surgery of Trauma, with a goal of 20-30 such training programs. (J. Trauma 2005;58:614-6; J. Trauma 2007;62:553-6; J. Trauma Acute Care Surg. 2012;72:4-10; J. Trauma 2010;68:753-60).
So we have the manpower, and we have a great distribution of trauma centers across this country, with authoritative legislation in most of the states. A total of 83% of the population is within 1 hour of trauma center care by ambulance or helicopter (JAMA 2005;293:2626-33).
Western rural states have the unsolved problem of adequate access to trauma center care, primarily because the population density cannot support such highly specialized centers. But with improved organization of regionalized transportation, this issue could be addressed, and these patients and resources concentrated. Urban America has a different problem in some locations, which is the oversubscribing of trauma centers because of ego, greed, lack of cooperation, and a presumed drive for prestige. This problem could be solved with legislation and changes in funding for trauma and acute care.
Trauma care systems are a model for regionalization of all time-sensitive illnesses, not just trauma, and not just surgical issues; the integrated trauma system model can be the future of regionalization of all health care.
Dr. Jurkovich, an ACS Fellow, is chief of surgery at Denver Health, and vice chairman of surgery, University of Colorado in Denver.
The Acute Care Surgeon
In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.
Surgical Trends
The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.
Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.
In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.
When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2
Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.
—Rohit Uppal, MD, MBA
A New Specialty
In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.
Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.
What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.
Strong Results
The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.
Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.
In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):
- Providing measurable quality improvement;
- Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
- Doing things other physicians had given up, such as indigent care and hospital committee functions;
- Creating healthcare teams to improve the working environment; and
- Taking care of acutely ill, complex hospitalized patients.7
We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.
We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.
Conclusion
We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH
Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.
References
- Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
- Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
- Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
- Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
- Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
- Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
- Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.
In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.
Surgical Trends
The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.
Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.
In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.
When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2
Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.
—Rohit Uppal, MD, MBA
A New Specialty
In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.
Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.
What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.
Strong Results
The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.
Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.
In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):
- Providing measurable quality improvement;
- Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
- Doing things other physicians had given up, such as indigent care and hospital committee functions;
- Creating healthcare teams to improve the working environment; and
- Taking care of acutely ill, complex hospitalized patients.7
We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.
We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.
Conclusion
We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH
Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.
References
- Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
- Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
- Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
- Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
- Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
- Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
- Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.
In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.
Surgical Trends
The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.
Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.
In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.
When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2
Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.
—Rohit Uppal, MD, MBA
A New Specialty
In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.
Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.
What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.
Strong Results
The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.
Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.
In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):
- Providing measurable quality improvement;
- Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
- Doing things other physicians had given up, such as indigent care and hospital committee functions;
- Creating healthcare teams to improve the working environment; and
- Taking care of acutely ill, complex hospitalized patients.7
We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.
We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.
Conclusion
We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH
Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.
References
- Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
- Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
- Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma. 2004 Sep;57(3):467-471.
- Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg. 2003 Oct;238(4):596-603.
- Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004 Jul;199(1):96-101.
- Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005 May;58(5):906-910.
- Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.