Elsevier

Surgery

Volume 155, Issue 5, May 2014, Pages 809-825
Surgery

Transforming Surgical and Interventional Care: Insights from the Robert Wood Johnson Foundation Clinical Scholars Program
A qualitative analysis of acute care surgery in the United States: It's more than just “a competent surgeon with a sharp knife and a willing attitude”

https://doi.org/10.1016/j.surg.2013.12.012Get rights and content

Background

Since acute care surgery (ACS) was conceptualized a decade ago, the specialty has been adopted widely; however, little is known about the structure and function of ACS teams.

Methods

We conducted 18 open-ended interviews with ACS leaders (representing geographic [New England, Northeast, Mid-Atlantic, South, West, Midwest] and practice [Public/Charity, Community, University] diversity). Two independent reviewers analyzed transcribed interviews using an inductive approach (NVivo qualitative analysis software).

Results

All respondents described ACS as a specialty treating “time-sensitive surgical disease” including trauma, emergency general surgery (EGS), and surgical critical care (SCC); 11 of 18 combined trauma and EGS into a single clinical team; 9 of 18 included elective general surgery. Emergency orthopedics, emergency neurosurgery, and surgical subspecialty triage were rare (1/18 each). Eight of 18 ACS teams had scheduled EGS operating room time. All had a core group of trauma and SCC surgeons; 13 of 18 shared EGS due to volume, human resources, or competition for revenue. Only 12 of 18 had formal signout rounds; only 2 of 18 had prospective EGS data registries. Streamlined access to EGS, evidence-based protocols, and improved education were considered strengths of ACS. ACS was described as the “last great surgical service” reinvigorated to provide “timely,” cost-effective EGS by experts in “resuscitation and critical care” and to attract “young, talented, eager surgeons” to trauma/SCC; however, there was concern that ACS might become the “wastebasket for everything that happens at inconvenient times.”

Conclusion

Despite rapid adoption of ACS, its implementation varies widely. Standardization of scope of practice, continuity of care, and registry development may improve EGS outcomes and allow the specialty to thrive.

Section snippets

Methods

We created a semistructured interview using the principle of reflexivity (reflecting upon the effect of clinical experience, literature review, and ongoing research on attitudes and preconceptions to decrease bias in both interviewing and analyses).34 Interview questions explored ACS implementation (eg, infrastructure, team organization, call coverage) and the evolution/future of ACS (see Appendix). The interview was piloted on senior acute care surgeons at centers familiar to the investigator

ACS model

All respondents described ACS as a specialty treating “time sensitive surgical disease,” including trauma, EGS, and SCC. Seventeen embraced the term “acute care surgery,” with 4 referring to “surgical hospitalists” or “in-house general surgeon.” However, one respondent disagreed stating, “we all went into this thing [surgery] ‘like I want to do the hairiest crap you can find me…people bleeding to death and dying and all that.’ I mean it couldn't be further from this hospitalist word of let me

Discussion

ACS has been theorized to improve productivity in an overburdened health care system, optimize outcomes, and increase the cost-effectiveness of EGS coverage.5, 6, 7, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 39, 40, 41, 42, 43 Our qualitative results from stakeholders at 18 hospitals with ACS programs show marked variability in the current implementation of ACS and suggest that, nearly a decade after the specialty first emerged, barriers may exist to realizing its benefits.

Greater quality

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      We pilot tested early versions of the survey with surgeons who perform EGS. We included questionnaire items if they were deemed relevant in our prior research or if they were chosen as best practices by our expert panel.16,21–23 Given the absence of a standardized definition of ACS, those who responded that their hospital's approach to EGS was a dedicated clinical team whose scope encompasses EGS (± trauma, ± elective general surgery, ± burns) were classified as ACS hospitals.

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    The research reported in this publication was in part supported by the University of Massachusetts Clinical Scholar Award (H.P.S.) through the National Center for Advancing Translational Sciences of the National Institutes of Health under award numbers UL1RR031982, 1KL2RR031981-01, and UL1TR000161. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

    H.P.S. was a member of the RWJ Clinical Scholars Program, Chicago, IL, 2003–2005.

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