Critical Care Implications in Acute Care Surgery

FIGURE 59.1 Baseline physician FTE supply and demand projections, 2006–2025. (From Center for Workforce Studies. The Complexities of Physician Supply and Demand: Projections Through 2025. Available at: http://members.aamc.org/eweb/upload/The%20Complexities%20of%20Physician%20Supply.pdf. Accessed August 12, 2015.)

Though the majority of residents choose to further specialize with fellowship training, they have not traditionally chosen to specialize in trauma and/or surgical critical care. Reasons behind this are complex and include the additional time commitment, nonoperative nature of a trauma surgery practice, a perception of a higher percentage of unfunded and underfunded patients, payment for effort/services that rely more heavily on evaluation and management coding and less on procedure-based coding, and a possible interference with elective operative schedule given the unscheduled nature of critical illness. More specifically, surgical residents’ opinion of trauma surgery is double-sided. Residents describe trauma surgery as clinically rewarding and recognize its importance but also recognize the nonoperative nature, high levels of stress and long hours without expected financial compensation (11). Additionally, trauma surgeons are viewed as being dissatisfied, a perception that resulted in 44% of the Surgical Critical Care fellowship positions going unfilled in 2011 (2). As a result, there are fewer general surgeons and even less trauma surgeons. With this, there are fewer persons available to take emergency department call and care for patients with time-sensitive general surgical conditions.

FIGURE 59.2 Projections of physicians by specialty group. (From Center for Workforce Studies. *The Complexities of Physician Supply and Demand: Projections Through 2025.* Available at: http://members.aamc.org/eweb/upload/The%20Complexities%20of%20Physician%20Supply.pdf. Accessed August 12, 2015.)

FIGURE 59.3 Cumulative percent growth in demand by specialty group. (From Center for Workforce Studies. *The Complexities of Physician Supply and Demand: Projections Through 2025.* Available at: http://members.aamc.org/eweb/upload/The%20Complexities%20of%20Physician%20Supply.pdf. Accessed August 12, 2015.)

EMERGENCY SURGICAL CARE AT THE BREAKING POINT

The provision of care to critically ill and injured patients challenges not only health care providers and medical centers, but is straining the health care system nationwide (13,14). According to the National Center for Health Statistics, 36 million people or 11.5% of the population had no health insurance in 2014 (15). From 1993 to 2013, there has been an increase of approximately 44% in the number of patients receiving care in emergency rooms across the country, while the number of emergency departments decreased by 558 (16). Nearly half of all hospital emergency departments reported that they were at or beyond capacity in 2005, resulting in ambulance diversion (5). This problem is more severe for major teaching institutions, with 79% of their emergency rooms at or exceeding capacity (17). The nation’s emergency medical system as a whole is overburdened, underfunded, and highly fragmented. As result, ambulances are turned away from emergency departments once every minute on average and patients in many areas may wait hours or even days for a hospital bed (2).

FIGURE 59.4 Survey results on resident opinion regarding surgical resident training. (From Yeo H, Bucholz E, Ann Sosa J, et al. A national study of attrition in general surgery training: which residents leave and where do they go? *Ann Surg*. 2010;252(3):529–534; Davis KA. EAST 2015 Presidential address: look both ways. *J Trauma Acute Care Surg*. 2015;79:1–9.)

Concurrently, the trend in patient care has shifted to the outpatient setting whenever possible in an effort to reduce costs. Consequently, hospitals have noted an increased acuity of inpatients, while simultaneously dealing with the demands for improved clinical efficiency and quality improvement. Operating rooms (ORs) are run at maximal efficiency with little slack in the system. Surgeons are increasingly pressured to maximize their productivity as a method of maintaining reimbursement (18). Almost all of surgical specialties contribute positively to the hospital margin, and therefore to the hospital’s overall financial stability (19). Therefore, it is in the hospital’s financial benefit to support surgical activity and utilize a model that will increase that activity such as an ACS model. Davis et al. (20) compared the hospital contribution margin over two time frames, before and after the implementation a practice paradigm where all trauma patients were admitted to an ACS team for at least 24 hours. With more trauma team oversight, there was a 10% increase in charges between the two time periods and the overall contribution model became positive were it had previously been negative. Additionally, collections and revenues markedly increased with trauma team oversight and a focus on billing capture. These financial benefits, both to physicians and to hospitals, are further support for the ACS model. Despite the fact that trauma has become more nonoperative and cognitive, as a service it can continue to contribute to a positive hospital margin. Integrating trauma into acute care surgery and perhaps incorporating an elective general surgical practice will only add benefit both providers and the hospitals in which they work.

O’Mara and colleagues (21) demonstrated the sustainability of an ACS model in a nontrauma setting. Evaluating emergency general surgery cases only, they demonstrated lower overall complications, decreased lengths of stay, and lower hospital costs, all attributable to the implementation of an ACS service at their institution. These findings were confirmed by Diaz et al. (22), who reported that despite a high severity of illness, overall mortality and hospital lengths of stay would be less when managed by a mature ACS service.

LAYING THE GROUNDWORK FOR ACS MODEL

Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings. 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 (2). Doubling as surgical intensivists, acute care surgeons provide not only a much needed service but a continuity of care, both operating on the acute surgical disorder as well as caring for the critically ill postoperatively, that is not matched in any other field.

The unscheduled nature of critical illness and injury, combined with the significant resources required to treat these diseases, continues to challenge health care providers and medical centers. The introduction of operative emergencies is inherently inefficient and disruptive to the smooth running of an OR schedule thereby adding stress to an already strained system, and increasing frustration of the surgeons and the staff. Additionally, the off-hours nature of most surgical emergencies requires that very costly resources be available 24 hours a day, regardless of utilization (23).

Sweeting et al. (24) evaluated at the change in relative value units (RVUs) before and after the implementation of an ACS program. This article compared an ACS program to the pre-existing elective surgery model. They showed that operative volume increased by 25% but it tended to be smaller cases with less RVUs per case (colectomy vs. incision and drainage of an abscess, for example). With this, overall RVUs were only up 21%. Additionally, the ACS division showed an increased percentage of uncompensated care relative to the department of surgery as a whole. There was also an increased write-off to bad debt and a worse net reimbursement as compared to the pre-ACS model. The authors calculated that the loss of clinical income due to lower RVU procedures and a declining payer mix meant that salaries could not be supported solely on clinical revenue generation and that fixed support would need to be augmented by about 28% to remain revenue neutral.

Therefore, hospital-based financial support and resources will be necessary in order to implement and maintain a rigorous ACS model. Wanis et al. (25) showed a positive impact with the initiation of an ACS model (decreased time to operating room (OR), length of stay); however, they attribute part of its success to the dedicated OR that was available daily to the acute care surgeons. Having this dedicated room contributed to the overall success of the model as well as surgeon satisfaction. Similarly to the trauma model, leaving an OR completely open for ACS means that room does not generate revenue and could lead to other case delays. However, Anantha et al. (26) showed that allocating an OR to the ACS service did not affect wait times for elective cancer surgeries. Additionally, cost modeling analysis of the ACS model, with a dedicated OR, has cost savings potential for the health care system without reducing overall surgeon billing (27). Having dedicated surgeons to this specific field is one hurdle, however, baseline resources, like a dedicated OR is critical.

ACS services must be staffed in such a way to assure continuity of patient. A cohesive group of surgeons dedicated to the service will assure accurate handoffs and consistency in patient throughput. There are various ways to implement the ACS model. Given the tripartite missions of acute care surgery, surgeons are often dedicated to either the ICU or a “floor” service, comprising either trauma, emergency general surgery, or some combination thereof. In busier institutions, elective cases are generally reserved for weeks when the ACS surgeon is “off-service,” depending on their average volume of emergency and urgent surgery. Some models may incorporate non-ACS surgeons so as to spread the call-out over a larger number of surgeons. This model is attractive to those surgeons who are interested in maintaining their “acute” surgical skills, as well as those who wish to augment their elective practice volumes with emergency room referrals.

Infancy of ACS Fellowship Training

In the early years of the 21st century, the leadership at the AAST responded to the crisis in access to emergency surgeons with the foundation for the training of surgeons in acute care surgery. The paradigm for ACS capitalized on the already existing training of trauma critical care surgeons while also enhancing their operative experience. Although the field of trauma surgery has become increasingly nonoperative over the last two decades, trauma surgeons remain among the few who can operate in multiple anatomic regions as well as care for the most critically ill patients. In 2008, the first AAST-approved ACS fellowship started. Since this time, there have been constant evaluations as to how to implement and improve the program (Table 59.1).

The core components of ACS are trauma, surgical critical care, and emergency general surgery with the training designed to create a versatile surgeon able to confront a host of acute surgical disease processes. The suggested curriculum includes focusing on clinical experience but also operative expectations of a trainee in an accredited program. An initial list of “essential and desirable” cases was created, which focused on a broad range of predominantly trauma case types divided into anatomic regions. This design attempts to ensure that a fully trained acute care surgeon is comfortable with a wide variety of anatomic exposures across all body regions (28).