Acute care surgery: An evolving paradigm

Author’s Accepted Manuscript Acute Care Surgery: An Evolving Paradigm Gregory J. Jurkovich, Kimberly A. Davis, Clay Cothren Burlew, Christopher J. Dente, Joseph M. Galante, Joel S. Goodwin, Bellal Joseph, Marc de Moya, Robert D. Becher, Viraj Pandit www.elsevier.com/locate/cpsurg

PII: DOI: Reference:

S0011-3840(17)30112-0 http://dx.doi.org/10.1067/j.cpsurg.2017.05.001 YMSG560

To appear in: Current Problems in Surgery Cite this article as: Gregory J. Jurkovich, Kimberly A. Davis, Clay Cothren Burlew, Christopher J. Dente, Joseph M. Galante, Joel S. Goodwin, Bellal Joseph, Marc de Moya, Robert D. Becher and Viraj Pandit, Acute Care Surgery: An Evolving Paradigm, Current Problems in Surgery, http://dx.doi.org/10.1067/j.cpsurg.2017.05.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Acute Care Surgery: An Evolving Paradigm Editors: Gregory J. Jurkovich, MD, FACS and Kimberly Davis, MD, FACS

A monograph for

Current Problems in Surgery Edited by: Stanley W. Ashley, MD, and FACS Elsevier Publishing May 20, 17

Page

1

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Authors and Affiliations Editors: Gregory J Jurkovich, MD FACS Professor and Vice-Chairman for Clinical Affairs and Quality Lloyd F. & Rosemargaret Donant Chair in Trauma Medicine Department of Surgery UC Davis Health System 2221 Stockton Blvd, Cypress #311 Sacramento, CA 95817 [email protected]

Kimberly A. Davis MD MBA FACS FCCM Professor of Surgery Vice Chairman of Clinical Affairs Chief of the Section of General Surgery, Trauma, and Surgical Critical Care Yale School of Medicine Trauma Medical Director Surgical Director Quality and Performance Improvement Yale-New Haven Hospital 330 Cedar Street BB310 New Haven, CT 06520-8062 [email protected]

Contribution Authors: Clay Cothren Burlew, MD FACS Director, Surgical Intensive Care Unit Program Director, Surgical Critical Care Fellowship Program Director, Trauma and Acute Care Surgery Fellowship Department of Surgery Denver Health Medical Center Professor of Surgery University of Colorado [email protected]

Christopher J Dente MD FACS Professor of Surgery Program Director, Acute Care Surgery Fellowship Emory University Deputy Chief of Surgery, Emory University at Grady Memorial Hospital [email protected]

Page

2

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Joseph M. Galante MD FACS Vice Chair for Education Division Chief Trauma and Acute Care Surgery Department of Surgery University of California, Davis 2315 Stockton Blvd Sacramento CA 95817 [email protected] Joel S. Goodwin II MD FACS Medical Director, OmniPoint Surgical Services General, Acute Care, Trauma and Surgical Critical Care 3100 Tower Blvd. Suite 406 Durham, NC 27707 [email protected] Bellal Joseph, MD, FACS University of Arizona Department of Surgery Division of Trauma, Critical Care, And Emergency Surgery 1501 N. Campbell Ave, Room 5411 P.O. Box 245063 Tucson, AZ 85724 [email protected] Marc de Moya, MD FACS Program Director, Acute Care Surgery Fellowship Associate Professor of Surgery Division of Acute Care Surgery Massachusetts General Hospital Harvard Medical School [email protected] Robert D. Becher, MD, MS Assistant Professor of Surgery Section of General Surgery, Trauma, and Surgical Critical Care Yale School of Medicine 330 Cedar Street BB310 New Haven, CT 06520-8062 [email protected] Viraj Pandit, MD The University of Arizona 1501 N Campbell Avenue Room 4334 Tucson Arizona 85724

Page

3

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

4

Introduction Gregory J. Jurkovich MD FACS & Kimberly A. Davis MD MBA FACS FCCM As with many things in medicine, the specialty of Acute Care Surgery was born out of necessity and innovation. Over the past several decades, a crisis in access to emergency surgical care has been identified, highlighted in an Institute of Medicine report entitled “Hospital Based Emergency Care at the Breaking Point” [1]. This crisis is a result of an insufficient number of physicians willing to participate in emergency call panels as well as a growing workforce shortage of general surgeons, which in turn is the result of an aging surgical workforce and increased surgical sub-specialization [2,3,4]. Surgical specialization has also altered the operative experience of trainees (residents) so that many general surgery graduates no longer feel comfortable taking care of a broad range of general surgical conditions, especially those that are complex and time sensitive [5]. The provision of care to critically ill and injured patients challenges not only healthcare providers and medical centers, but is straining the health care system nationwide [5,7]. 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 [8]. Nearly half of all hospital emergency departments reported that they were at or beyond capacity in 2005, resulting in ambulance diversion [9]. This problem perhaps is more severe for major teaching institutions, with 79% of their emergency rooms at or exceeding capacity [10]. 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 are run at maximal efficiency with little slack in the system and surgeons are increasingly pressured to maximize their productivity as a method of maintaining reimbursement [11]. The unscheduled nature of critical illness and injury, combined with the significant resources required to treat these diseases, challenge health care providers

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

5

and medical centers. The introduction of operative emergencies is inherently inefficient and disruptive to the smooth running of an operating room schedule thereby adding stress to an already strained system and increasing frustration and “burnout” of 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 [12]. As the sickest of patients are using the hospital emergency departments as their access to health care, the more disruptive this is for hospital bed control and level loading of operating rooms with electively scheduled patients. This has required a commitment of hospitals to a dedicated roster of surgeons, operating rooms, and intensive care unit beds that have wide variation in their use and an acceptance of this inefficiency. Just as the needs of the injured patient drove the development of the field of trauma surgery, so are the needs of the emergency general surgery patient driving the development of the acute care surgery paradigm under the auspices of the professional society of the American Association for the Surgery of Trauma [6] This specialty enhances the training of young surgeons in the three areas of trauma, surgical critical care, and time-sensitive general surgery. This monograph explores the development of the training and practice paradigm of Acute Care Surgery, its role in academic teaching centers and community hospitals, the benefit it provides patients, and ends with some predictions for the future. We hope you enjoy reading it.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

6

What is Acute Care Surgery? Kimberly A. Davis MD MBA FACS FCCM & Gregory J. Jurkovich MD FACS What is Acute Care Surgery? Acute Care Surgery is a training paradigm that better prepares graduating general surgery residents for a career that encompasses the triumvirate of trauma, surgical critical care, and emergency general surgery. This trinity of practice is focused on critically ill patients with surgical diseases, all with a time-sensitive nature to their care. It is a response to patient needs, and the most efficient way to provide hospital surgical care for these patients. 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 trauma patients. [The care of these patients requires around-the-clock readiness for the provision of comprehensive care, a 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 the face of often-unrecognized comorbidities. 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 [3]. As surgical intensivists, acute care surgeons provide not only a much-needed service but a continuity of care, functioning as both operating surgeons in patients with acute surgical disorders as well as caring for the critically ill postoperatively [13]. Does the ACS model of care work? 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 intensive care unit or a “floor” service comprised or either trauma, emergency general surgery or some combination thereof. Some models incorporate

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

7

general surgeons to better allocate nighttime call responsibilities. 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. Other models consist of surgeons with fellowship training in either surgical critical care or acute care surgery coverage 24 hours a day, 7 days a week. Hospital based financial support and resources are necessary to implement and maintain a rigorous ACS model. Sweeting et al. evaluated at the change in 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 entire department of surgery. There was also an increased write-off to bad debt and a worse net reimbursement as compared to the preACS 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 [14]. Wanis et al. showed a positive impact on patient throughput with the initiation of an ACS model (decreased time to OR, LOS) however they attribute part of its success to the dedicated operating room 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 [15]. 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. showed that allocating an OR to the ACS service did not affect wait times for elective cancer surgeries [16]. 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 [17]. Having dedicated surgeons to this specific field is one hurdle, however, baseline resources, like a dedicated operating room is critical.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

8

Several studies have focused on surgeon productivity since the implementation of an acute care surgery model. Barnes et al. compared operative productivity before and after the implementation of acute care surgery and demonstrated a 66% increase in operative volume with an ACS division in place. Similarly, there was an increase in Evaluation and Management (E&M) work Relative Value Unit (wRVU) production as well as a rise in procedural wRVU production for both ACS and non-trauma surgeons [11]. Other studies have also shown an increase in OR cases and billing as well as an increase in surgeon satisfaction after the implementation of ACS [18]. The impact of ACS service models As ACS services become an increasingly common modality to provide care to patients with time critical general surgical disease (trauma, emergent or urgent general surgery), so grows the need for a surgical workforce trained in acute care surgery. As with the addition of any surgical fellowship training, there is concern for how the current general surgery resident training will be impacted. Dinan et al compared case volume among the general surgery residents before and after the initiation of the AAST approved ACS fellowship at a Level I trauma center. The study examined ACGME case log data, both before and after the initiation of the ACS fellowship and found that there was no significant change in the number of cases performed by the chief residents. Furthermore, residents were queried about the added value of the ACS fellow. Overall there was a positive opinion of the fellows as teachers and most agreed that the fellow did not detract from the residents' experience [19]. Additional studies have focused mainly on resident and surgeon interest and satisfaction with Acute Care Surgery. Recruitment into the field of trauma and critical care surgery was traditionally poor, as demonstrated by approximately 18% of fellowship positions unfilled in 2011. In 2015, this has improved to only 10% of positions going unfilled [20]. In 2012, Coleman et al. surveyed residents regarding a career path in Acute Care Surgery, which yielded a greater interest and understanding of Acute Care Surgery as a career [21]. Overall, these studies showed a much greater interest and understanding of Acute Care Surgery as a career choice, encompassing surgical critical care and emergency surgery.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

9

A Canadian study looked at surgeons' satisfaction within an ACS model compared to those with a traditional call schedule. Those within the model, on average, had higher satisfaction scores than those surgeons not using an ACS model [22]. In Barnes’ paper, both ACS surgeons and non-ACS surgeons reported improved job satisfaction with the implementation of an ACS service, stating they would prefer to work in a department that incorporated an ACS model [11]. As the fellowship matures and acute care surgeons enter the workforce, this will hopefully become a more attractive option for rising surgical residents. In addition to improved productivity, interest, and satisfaction, other studies have emphasized the ACS model as improving patient throughput. Multiple studies in the North America, Australia and Asia have demonstrated the efficiency and utility of an Acute Care Surgical model. Most these studies looked at the effectiveness of an ACS model as it pertained to appendectomies, cholecystectomies and small bowel obstruction, as these are the most common ACS operations performed. Cubas et al. showed a statistically significant decrease in time to surgical consultation, decreased time to the operating room, fewer complications and a reduced length of stay for appendectomies performed within an ACS model [23]. Again, looking at appendectomies, Fu et al showed a decreased amount of time in the Emergency Department by approximately 7 hours in Taiwan and Pillai et al in Australia demonstrated an increase in the proportion of daytime procedures [24,25]. Michailidou et al showed similar results when looking exclusively at cholecystectomies with 75% of patients undergoing an operation within 24 hours in the ACS group as compared to 59% in the non-ACS group [26]. With a slightly different perspective, Khalil et al. compared the acute care surgery model between American College of Surgeon Committee on Trauma (ACS-COT) approved level 1 trauma centers (ACS-COT-TCs), non-ACS verified level 1 trauma centers (TC) and non-trauma centers (NTCs). This study showed that patients managed in ACS-COT-TCs had significantly shorter hospital stay, lower complication rate and lower overall hospital costs when compared with patients managed in both TCs and NTCs [27].

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

10

Analysis of the Rhode Island Hospital NSQIP database determined that there exists a greater than 10% failure-to-rescue rate in the surgical population. Twenty percent of the patients with the greatest risk for developing postoperative complications account for approximately 90% of failure to rescue. With complications of medical or surgical care being one of the most frequent hospital-based diagnoses (exceeding even cholecystitis, intestinal obstruction, and appendicitis), acute care surgery offers the specialty expertise needed to provide the hospital surgical rescues required to optimally address these complications. [28] With the broad terrain of settings where acute surgical care is required, it is very clear that the Acute Care Surgery model will not be the complete answer to the nationwide workforce needs. Considering the medical landscape of this nation, with a well-documented decline in the general surgery workforce, a paradox is unveiled, given the fact that the general surgeon specialist remains the cornerstone of emergency surgical care across the country. This is problematic because of the more than 3,000 counties in the United States, as there are nearly 1,200 counties without a general surgeon. There are an additional 358 counties with at least one surgeon but below the workforce threshold need. Thus, almost half (1,525) of all US counties have less than the lowest recommended standard for access to a general surgeon specialist. [29] There is no question that the establishment of both the Acute Care Surgery model and the Acute Care Surgery fellowship is needed to begin addressing the health care disparities in acute surgical care. However, given the high number of patients needed to sustain this model of hospital-based care, the Acute Care Surgery is now primarily in practice in larger urban/suburban hospitals. While regionalization of emergency surgical care is an option for the sickest of these patients, the rural general surgeon remains a linchpin in providing emergency general surgery care in much of the country [32]. An expected corollary to this aim in definitively addressing this health care disparity is the need for Acute Care Surgery to be an essential component of the curriculum for general surgery training, at least for those who are planning a more rural-based, broad area of practice. This also might require expanding or altering core general surgery. The rationale for this is the fact that it will be the general surgeon who will likely fill that workforce void in the community setting. There will be a requisite

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

11

skill set that the general surgeon specialist needs to provide optimal care for the surgical emergencies and critically ill patients who reside in those community settings not populated by Acute Care Surgeons. [30] Conclusions: The acute care surgery model appears to provide an efficient 24-hour coverage for surgical emergencies, providing not only surgical care but also postoperative critical care in a timely and efficient fashion. Proven benefit in patient care combined with cost effective hospital resource management is driving the wider adoption of the ACS model. It should follow that trainees (residents) will find this a vibrant, satisfying, and sustainable career model, and more approved AAST-fellowships for the training of these surgeons should arise. The core components of acute care surgery (ACS) fellowship training (trauma, surgical critical care and emergency general surgery) are designed to create a versatile surgeon able to confront a host of acute surgical disease processes. The combination of surgeon shortage and poor access to emergency surgical care drove the creation of the ACS model. ACS services allow the time-critical delivery of emergent and urgent surgical care, in the face of an identified surgeon workforce shortage. The ACS practice model will continue to be interpreted differently among various hospitals. 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. Acute care surgeons are uniquely positioned to impact health care cost containment and improve care in the United States as mandated by the Affordable Care Act of 2010. Cost savings can be actualized, focusing on throughput and the use of standardized, evidence-based, consistent care that can optimize care delivery. Acute care surgeons stand at the front line of care delivery for the patients who are most critically ill and for the injured surgical patients with time-sensitive diseases. Getting the right patient to the right venue at the right time is the paramount skill that the acute care surgeon, through training and experience, adds to the value equation [31].

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

12

Acute Care Surgery: Developing the Curriculum Marc de Moya MD FACS & Clay Cothren Burlew MD FACS Over the past decade, Acute Care Surgery (ACS) has become a defined entity incorporating trauma surgery, surgical critical care, and emergency general surgery. In 2005, the American Association for the Surgery of Trauma (AAST) defined Acute Care Surgery and created a fellowship training program to prepare for this practice paradigm. (1) The goal of the fellowship curriculum is to produce well-trained surgeons who are versatile in the management of the breadth of acute surgical disease processes. (2) Subsequently there have been several measures taken to refine this curriculum and better define its goals and objectives. Training Paradigm Structure The original inception of ACS fellowship training emphasized the three core components of ACS (trauma, surgical critical care, emergency general surgery) while allowing individual programs some latitude in specific structure. The ACS fellowship was designed to follow an ACGME accredited general surgery residency, meaning an ACS fellow must have completed an accredited general surgery residency. The 2-year fellowship curriculum incorporates a surgical critical care residency combined with advanced operative experience and management of critically ill and injured patients.(3) The first year generally consists of a previously established ACGME-approved surgical critical care year in the home institution, followed by the second year with rotational experience in specific operative arenas and subspecialty areas critical to trauma and emergency general surgery patient management. Delineated rotations were outlined by the AAST executive committee as part of the fellowship program requirements (Table 1). Specifically, operative experience had to be assured in the areas of thoracic, vascular, and hepatobiliary surgery, as well as competence in bronchoscopy and upper and lower endoscopy. Additional exposure to the areas of orthopedic surgery, neurosurgery, and interventional radiology were encouraged. Elective rotations were to be tailored by individual program capabilities as well as the interests and needs of the fellow.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

13

In addition to rotational requirements, programmatic requirements included participation in acute care surgery call by the fellows for at least 52 nights over their 2year fellowship. Elective surgical cases were also expected during the fellowship as these were thought to be an essential component of fellowship training.(4) Finally, fellowship programs were to be managed by program directors who are board certified in general surgery and surgical critical care, and are also members of the AAST with ongoing scholarly activity. The academic environment, with fellow generated research as well as training to become effective teachers, was elemental to the fellowship paradigm. Since the initiation of these program requirements, twenty fellowship programs have been approved with these formal elements. The approval process by the AAST involves submission of the Program Information Form (PIF) that documents the institutional capabilities, educational rationale, and rotational elements of a specific fellowship. A site visit by two senior members of the Acute Care Surgery committee of the AAST verifies the educational content and rotational operative experience, and includes a summary report of the program’s strengths, weakness, and if any exist, deficiencies. Final approval of the program requires written approval by the Acute Care Surgery committee and the AAST Board of Managers. Refining the Curriculum Over the past decade, there has been growth and maturation of the ACS fellowship programs. At its inception, the Acute Care Surgery Committee of the AAST, composed of 25 appointed AAST members, was developed to design and implement the fellowship training components. Subsequently, the ACS Committee sought to encourage institutions to initiate ACS fellowships by assisting with programmatic development. Following the expansion to a desired target of 20 accredited programs, the ACS Committee continues now focuses on the refinement of the educational curriculum, the evaluation of the educational component of the fellowships, and close follow-up of the graduates’ experience and operative practice. The first steps of educational maturation by the Committee entailed two separate evaluations of the fellows’ operative experience. In 2014 the first iteration of the case logs for the ACS fellows was reviewed by Dente, et al.(5) They concluded that

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

14

the average number of cases done by the fellows was approximately 200 during the more operative year (2nd) of the fellowship. Also noted was variability in the types of cases, with approximately 50% of fellows’ operative experience failing to meet the essential and desired cases as outlined by the AAST. During this time a new case log system was being developed to better align the reports provided to the program directors with the AAST operative curricular requirements. In 2015, Duane et al. reported a follow up study evaluating the case logs.(6) They determined that there were limited experiences in head and neck and pediatric cases. They concluded that programs must develop creative ways to ensure essential cases as outlined by the AAST are being met. Recognizing that the fellows’ case log perhaps only captures a portion of the operative experience and that trauma cases alone do not provide adequate exposure to some of the more complex cases, the Committee refined the curriculum to include specific operative requirements that are organized by anatomic subsections (Head/Neck, Thoracic, Abdominal, Vascular) as well as organ based management. It is the totality of training in advanced operative techniques over the breadth of anatomic locations that remains one of the unique aspects of ACS.(7) This modification in the operative case requirements more closely mirrors the defined case volumes required of other specialties by the American Board of Surgery (ABS). The implemented case volume requirements also serve as a “real time road map” for both fellows and program directors; this helps adjust rotational experiences to ensure fellows are involved in the most complex cases that will augment their General Surgery residency experience and benefit their future care of the critically ill and injured patient. Real time analysis of case volumes and operative components are available through the AAST instituted case log tracking system. In 2015 this system was updated to provide program directors with an easy format for review and tracking. The portal provides the total number of cases in each operative category and then provides a breakdown of specific cases for further analysis. Another component of the ACS Committee’s ongoing evaluation of the educational component of the fellowships includes the development of a rigorous written examination. In addition to taking the ABS examination for Surgical Critical

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

15

Care, ACS fellows must also take the AAST examination after their second year of training. A formal subcommittee of the ACS Committee of the AAST analyzes test metrics, re-structures the exam, and adds new questions to the exam on a yearly basis. To further enhance the feedback and educational core to both fellows and program directors, the AAST initiated a “pre-test evaluation”. The concept, introduced in 2015, is to test all fellows within the first six weeks of the start of the second year of their fellowship. Formal results, subcategorized by anatomic elements and disease states, are distributed to fellows and their program directors. This provides a metric for specific fellow and fellowship directed learning over the course of the subsequent year prior to the final test at graduation. The newest initiative of the ACS Committee is the creation of a formal educational curriculum composed of content-specific modules. The purpose of the curriculum is two-fold. First, it coalesces current publications, knowledge, and expert opinions on difficult to research topics that are core to the fellowship. Second, it comprises the framework of expected learning and subsequently directs the year-end testing of the fellows. This didactic curriculum will consist of over 40 educational modules in abbreviated and expanded formats. The modules currently cover several vascular and thoracic topics germane to ACS and are available to all fellows via the AAST website. While both abbreviated and expanded modules include up-to-date core information, the expanded modules include commentary from senior acute care surgeons with useful tips and tricks. Ongoing Evaluation of the Educational Process The hallmark of any fellowship is to provide a structured learning environment with graduated levels of responsibility and autonomy. Appropriate and graduated supervision of the fellows is assured with periodic performance assessments. This assessment tool has been formally structured by a subcommittee of Program Directors of the ACS Committee of the AAST. In addition to the development of a supervision documentation tool, that subcommittee is also developing a Milestones document that incorporates the following domains: care for diseases and conditions, performance of operations or procedures, coordination of care, teaching, self-directed learning,

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

16

improvement of care, maintenance of physical and emotional health, and performance of assignments or administrative tasks. The combination of these two processes along with the typical semi-annual fellow review and year-end programmatic review ensures the educational paradigm remains intact, focused, and under continual review at the local level. At the national level, the AAST endorses a recertification process for all AAST approved ACS programs every six years. This review, much like the initial certification of programs, entails submission of educational and rotational documents followed by an in-person site review by two members of the ACS Committee. Formal summative evaluation by the two reviewers is submitted to the ACS Committee followed by the Board of Managers for final approval. During the second year of the fellowship, individualized rotational experience may be implemented based upon ongoing evaluation of the fellow’s case logs, experience, and general goals. One option for an expanded learning environment is through international rotations. International fellowship rotations should provide fellows with additional experience in global health and often acute care surgery in a more austere environment; the AAST ACS Committee must formally approve them. The sponsoring institution of the international elective must provide clear goals and objectives, and ensure the fellow has adequate supervision in a safe environment. Conclusion The optimal curriculum for acute care surgery fellowships remains in evolution. A robust two-year core curriculum has been in effect since 2005. The upgraded operative requirements, case log tracking system, programmatic reviews, and postgraduation follow-up will provide on-going curricular feedback. Current fellowship graduates report their training prepared them for practice as acute care surgeons and their practice demonstrates use of their acquired advanced operative training.(8) Future directions may include more robust real-time operative and resuscitation assessments of fellows, expansion of learning content/educational modules, and utilization of cadaver based tools to assess operative skills. The number of applicants to

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

17

these programs has dramatically increased over the last decade as the need for bettertrained acute care surgeons increases. Table 1 (Chapter III): Required Clinical Rotation

Length

1. Surgical Critical Care (as per ACGME

12 months

guidelines)

2. Core Operative Year -Trauma/Emergency General Surgery

3-6 months

(including minimum of 52 calls) -Thoracic Surgery

1-2 months

-Transplant/Hepatobiliary/Pancreatic

1-2 months

-Vascular/Interventional Radiology

1-2 months

3. Suggested Rotations -Neurosurgery

1 month

-Orthopedic Surgery

1 month

-Electives (Burn Surgery, Pediatric Surgery,

1-3 months

Endoscopy, Imaging, Plastic Surgery, Prehospital etc.) Total

24 months

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

18

Current AAST Fellowships in Acute Care Surgery Christopher J Dente MD FACS The ultimate goal of training a surgeon in Acute Care Surgery (ACS) is to create a physician competent in the treatment of a wide variety of acute surgical illness across a wide array of anatomic regions. In essence, it is the creation of a specialist that is defined neither by an anatomic region nor a specific type of disease process, but by the time sensitivity of that disease process. Many have termed this practice pattern as similar or identical to the practices of general surgeons in past decades. (9) While this opinion may have some merit, it is a reality that the training paradigms of general surgery residencies have evolved in the modern era into concentrated areas of specialty practice, brought on by the increasing body of surgical knowledge, workplace restrictions, billing considerations for faculty and generational changes in practice interests. Indeed, the broad based general surgeon with an interest in the care of a wide variety of diseases has become increasingly hard to find outside of rural America, and especially hard to identify in academic centers. This has led to a crisis in access to emergency surgical care, which has been recognized since the dawn of the new millennium. (10) Because there is an acute need for a surgical specialist equipped to handle a wide variety of emergencies, the American Association for the Surgery of Trauma (AAST), amongst others, has worked diligently to formulate a training program designed to create a cadre of surgeons with this expertise. The type of training paradigm, however, is challenging to create in an era where specialization generally leads to narrowing of focus to specific anatomic regions or disease processes. This section will describe the current available fellowships, their location, the length of time they have been in place and some of the unique challenges they must overcome to meet the needs of a patient population in need of emergent surgical care.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

19

The American Association for the Surgery of Trauma Training Model for Acute Care Surgery To understand the challenges faced in training a “broad-based” specialist, it is important to understand the current training model overseen by the AAST. Indeed, over the last fifteen years the training requirements laid out by the AAST for Acute Care Surgery fellowships have evolved significantly. The original curriculum document was approved in 2007, revised in 2010 and revised a second time in 2014. The current curriculum is available on the AAST website (11), and while a detailed review of the curriculum is presented in the previous sections, several points should be emphasized. First, while the fellowship is a two-year fellowship, the AAST mostly directs the content of only one year, as the other year is an ACGME certified surgical critical care fellowship. Therefore, the rotation schedule and most of the operative experience will come in the trainee’s investment of an additional 12 months of experience in addition to the standard fellowship (residency) in surgical critical care. Second, the expectations for the faculty, program director and program infrastructure, along with the roles and responsibilities of the ACS trainees is similar or identical to the roles and responsibilities they have during their ACGME training. This effort is designed to facilitate the evolution of ACS into an ACGME specialty board if changes in future board-certification for surgery continue to evolve into a core plus specialty training for all residents. On top of these requirements, however, the AAST has begun to define ways for ACS trainees to develop into independent practitioners in what is, for most, their terminal training. Things such as supervised, but independent, trauma call and the coverage of general surgery cases or services are present throughout many of the fellowships. How these are regulated is being reviewed and formalized by the Acute Care Surgery Program Director’s Committee of the AAST. Next, the operative and didactic curriculum has been refined several times over the last decade. The operative curriculum now consists of defined case categories and exposures with expectations for minimum number of cases.(7) These operative requirements were decided upon after a careful review and cataloguing of early ACS fellows’ operative experiences and are designed to ensure a broad based anatomic experience.(5) The initial analysis led to the conclusion that there was a dearth in

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

20

several important complex types of cases in the experience of many fellows. As such, several of the previously “suggested” rotations are now required clinic experiences. (Table 1) However, programs are left with the flexibility to use the opportunities within their departments to craft those experiences. For example, several programs without easy access to a good senior experience on a hepato-biliary service have created rotations that allow fellows to be in the organ procurement call pool. Indeed, it is left to the fellowship to ensure that the case requirements are met, with the required rotation schedule allowing for a fair bit of flexibility in a program’s experience. Essentially, a program is measured by its ability to expose a senior trainee to a wide variety of complex cases in all anatomic regions rather than by its specific rotation schedule. That flexibility has created programs with relatively divergent schedules, as will be discussed below. Finally, the didactic knowledge base is still evolving. Under the direction Clay Cothren-Burlew, the ACS committee of the AAST is currently creating a web-based curriculum that is available to in-training fellows and faculty and is comprised of learning modules on a wide variety of topics. Furthermore, an in-training exam has been designed and given this past academic year and ongoing revision of the completion examination, given at the end of the ACS year is allowing it to sync with the components of the didactic curriculum. In short, both the didactic and operative expectations for ACS training have not only evolved but also have crystallized significantly over recent years, which have allowed for flexibility in training programs to design rotational schedules to benefit their trainees and maximize their institutional strengths. Interested institutions can find the materials required to create an application to the AAST for an ACS fellowship on the AAST’s website.3 Current Acute Care Surgery Fellowship Programs Currently 21 AAST certified Acute Care Surgery fellowship exist across the United States, which have graduated more than 50 trainees as of June 2016. (Table 2). Each fellowship has an established program director that is either a member of the AAST or has one as a mentor. As previously mentioned, the training paradigm allows

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

21

for some flexibility in rotation scheduling which allows programs to accentuate their institutional strengths and tailor a trainee’s experience to their individual needs. Differences in the way programs provide broad based experiences in Acute Care Surgery can be highlighted by examining three specific programs in a relatively tight geographic region. The fellowship at Wake Forest Baptist Medical Center in WinstonSalem, NC was administered by Michael Chang with the support of J Wayne Meredith since its accreditation by the AAST in 2012. The leadership of the program has recently been transitioned to Nathan Mowery who continues to operate the fellowship with the mentorship of Drs. Chang and Meredith. During their ACS year, rotations include: trauma/emergency general surgery (7 months), vascular (1 month), interventional radiology (1 month), thoracic (1 month), orthopedics (1 month) and neurosurgery (1 month). Elective rotations include minimal invasive surgery and hepato-biliary surgery, as well as research. The leadership of the program is blessed with a large tertiary referral center with large volumes of subspecialty elective cases that allow for a broad based operative experience, which is reflected in the case logs of their trainees. Based on feedback from the original site review, the trauma experience has become more extensive and formalized and they are also easily able to demonstrate an adequate number of trauma evaluations and cases. There is an extensive and growing didactic curriculum and the trainees are routinely involved in the performance improvement programs of the division, as is appropriate for a senior trainee. There are significant opportunities for a variety of research projects and several fellows had one or more active projects. Contrast this experience with the ACS fellowship at Eastern Carolina University/Vidiant Medical Center, in Greenville, NC, which is administered by Eric Toschlog. Eastern Carolina University is a tertiary center in a very rural region and much of the trauma seen in this center comes as transfers from referring facilities. The trauma and emergency general surgery services are split with the trainee generally spending 3 months on either service. The rest of the rotations can be tailored to the needs of the fellow with month long experiences on thoracic, vascular, hepato-biliary, burn and even urologic surgery possible. Given the relative volume of cases, the program has great flexibility in molding the experience to suit the trainee. Moreover,

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

22

the general surgery program director is part of the core ACS faculty which allows for superb coordination with the general surgery residency training. Finally, the Acute Care Surgery program at Emory University/Grady Memorial Hospital provides a broad based operative experience that is concentrated on the trauma service. Given the high volumes of penetrating and other operative trauma, trainees spend 8 months covering the trauma resuscitation bays. Their experience is supplemented by a one-month thoracic experience and one month on the vascular service. They also rotate with the orthopedic service for a month and spend a month at the Sheperd Rehabilitation Center. To ensure they have enough exposure to hepatobiliary anatomy, the trainees are also part of the procurement call pool and participate in multiple organ harvests during their training. These three training programs all provide a senior trainee with a broad-based experience, although each does so in a different way. If one examines each of the other approved fellowships, one would also find variations in the rotational schedules and experiences but with one singular goal. Ultimately each fellowship is assessed on its ability to meet the operative expectations, and clinical experience foundation established by the AAST. Fellowships are reviewed by the AAST Acute Care Surgery Committee for re-verification approximately every four years. During these visits, site reviewers spend time carefully reviewing the operative experiences of the fellows with an eye towards ensuring they are receiving an adequate breadth to their training. Graduates If the goal of ACS training is to create a broad-based surgical specialist, it is important to understand the practice patterns of graduates of ACS training programs. While this young specialty continues to evolve and mature, a recent survey of 56 graduates suggest that the majority are working in teaching institutions and level 1 or 2 trauma centers.(8) The current practice mix includes about 10% elective surgery, 40% emergency general surgery, 32% trauma and 25% critical care, with a small minority of other interests. Most graduates are currently satisfied with their scope of practice and case mix as well as their lifestyle. The clear majority would encourage others to pursue a fellowship in ACS.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

23

Summary Current training in Acute Care Surgery is a complex endeavor for a variety of reasons, most notably the counter intuitive nature of a “broad based” specialist. The Acute Care Surgeon, however, fills an important role in a hospital system and an important role for the patient populations they serve. Current training programs seem to meet the training needs of young surgeons entering their terminal training, although they use different means to do so. Ongoing efforts to refine the didactic knowledge base and operative curriculum should lead to increased standardization of the training although it will be important to maintain some flexibility in rotational requirements to allow for tailoring of the experience to fit the needs of each senior learner.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

24

Table 1 (Chapter IV): Original vs. Current Rotational Requirements Original Rotation Schedule (2007)*

Current Rotation Schedule (2014)$

Year

Trauma and Surgical Critical Care

Trauma and Surgical Critical Care

1

(ACGME compliant SCC Residency)

(ACGME compliant SCC Residency)

Year

Emergency and Elective Surgery

Emergency and Elective Surgery

2

Trauma/Emergency Surgery (2-3 mo)

Trauma/Emergency Surgery (2-3 mo)

Suggested: Thoracic (2-3 mo),

Thoracic (1-2 mo)

Transplant/Hepatobiliary/Pancreatic (2-

Transplant/Hepatobiliary/Pancreatic (1-2

3 mo), Vascular/IR (2-3 months),

mo)

Orthopaedics (1 mo), Neurologic Surgery

Vascular/IR (1-2 mo)

(1 mo)

Suggested: Orthopaedics (1 mo),

Recommended: Burn Surgery and

Neurologic Surgery (1 mo)

Pediatric Surgery, Endoscopy, Imaging,

Recommended: Burn Surgery and

Plastic Surgery, etc.

Pediatric Surgery, Endoscopy, Imaging, Plastic Surgery, etc.

* Adapted from original Program Requirements document, AAST website $ Adapted from current program requirements document, AAST website SCC = Surgical Critical Care mo = months Table 2 (Chapter IV): Current AAST certified Acute Care Surgery Fellowships

Program

University of Nevada

Location

Las Vegas, NV

Year

Program

Certified

Director

2008

John Fildes

Email address

# of Positions

[email protected]

3

da.edu University of Colorado

Denver, CO

2008

Clay Cothren

[email protected]

Burlew

g

1

University of Pittsburgh

Pittsburgh, PA

2008

Jason Sperry

[email protected]

2

University of California,

Fresno, CA

2009

Jim Davis

[email protected]

1

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

25

Fresno University of Maryland

Baltimore, MD

2009

Jose Diaz

[email protected]

5

Massachusetts General

Boston, MA

2010

Marc Demoya

[email protected]

1

Hospital University of Texas Health

g Houston, TX

2010

Bryan Cotton

Science Center Vanderbilt University

[email protected]

2

mc.edu Nashville, TN

2011

Addison May

Addison.may@vanderb

4

ilt.edu Wake Forest Baptist

Winston-

2012

Nathan Mowery

nmowery@wakehealth

2

Medical Center

Salem, NC

East Carolina

Greenville, NC

2012

Eric Toschlog

[email protected]

2

Tucson, AZ

2012

Terence O’Keefe

[email protected]

2

.edu

University/Viadent Medical Center University of Arizona

na.edu Baystate Medical Center

Springfield,

2012

Andrew Doben

MA Hartford

Hartford, CT

Andrew.doben@baysta

1

tehealth.org 2012

D’Andrea

D’andrea.joseph@hhch

Joseph

ealth.org

Mbaga

Mbaga.walusimbi@wri

Walusimbi

ght.edu

2013

Linda Maertz

[email protected]

1

2014

Indermeet

Indermeet.bhullar@orl

1

Bhullar

andohealth.com

Alicia Mohr

[email protected]

Hospital/University of

1

Connecticut Wright State University

Yale University

Dayton, OH

New Haven,

2012

1

CT Orlando Regional Medical

Orlando, FL

Center University of Florida-

Gainesville, FL

2014

Gainesville Indiana University

1

l.edu Indianapolis,

2015

Mark Falimirski

[email protected]

1

2015

Christopher

[email protected]

3

IN Emory University/Grady

Atlanta, Ga

Dente

Acute Care Surgery: An Evolving Paradigm

San Antonio Military

San Antonio,

Medical Center

TX

Carolinas Medical Center

Charlotte, NC

Jurkovich & Davis

2016

Page

Christopher

26 1

White 2017

Ron Sing

Ronald.sing@caroliash ealthcare.org

1

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

27

Acute Care Surgery in Rural and Community Hospitals Joel S. Goodwin, MD FACS The concept of an Acute Care Surgical program in a community hospital can be distilled into two fundamental requisites. The first is a formal partnership between surgeons and the hospital. The second is an organizational structure that allows for proper, timely and efficient surgical care through the continuum of the illness and recovery. This is true in any setting. There is growing literature that is reporting the rationale, strategies, trends, problems, and successes of acute care surgery model in larger tertiary academic centers. (12-15) At least one recent paper by Kalina (16) reports measurable success with an acute care surgical program at a non-ACS trauma verified, non-academic, suburban 250bed hospital. However, as far as I have could ascertain, there is no literature addressing the systematic approach to providing an acute care surgical program in rural or smaller community hospitals. Surgeon Workforce and Cost of Care The current shortage of well-trained general surgeons in the United States is, now, predominantly a geographic phenomenon with isolated and rural communities the most adversely affected constituents. The data is compelling that this shortage is real, will worsen soon, and will be disproportionately hard on these same regions at the exact time that the demographic spike of aging baby boomers will drive surgical utilization up. (1720) No amount of magical thinking will make this otherwise. If there are no surgeons, patients in these areas will need to be transported to larger centers for definitive care. The cost of transfer, the disruption of daily life of family members, and the increased morbidity of delayed definitive care are all likely. This should be an alarming sociological phenomenon. Two recent studies are starting to lay the evidence to confirm these fears. Misercola, et al, examined patients transferred from rural hospitals to a tertiary center in Portland, Maine.(21) They were somewhat surprised to conclude that the transfers reflected factors “other than patient characteristics” indicating a lack of general surgical resources in those rural communities. A study by Narayan et al, looked at financial data from nearly 450,000

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

28

patients in the state of Maryland and showed that the costs to provide care to emergency surgery patients in the larger, tertiary trauma centers were significantly higher than in the non-trauma centers, twice as expensive if the ICU was required.(22) Excluding the expenses associated with the medical care, the additional logistical and financial burden this puts on patients, families, and the receiving hospitals is probably measurable and certainly involves significant opportunity costs. This phenomenon of transporting emergency surgical care to tertiary centers from smaller outlying hospitals is economically as well as personally onerous. However, with proper planning, resources, strategic alliances and organizational structure, this may be preventable in many locales by providing care closer to home, as it has been done historically. Acute Care Surgery: “The Right Stuff” Acute Care Surgery is a rich but nuanced concept. One of the most important requirements is a broad skill set. Most rural surgeons of my generation or older (>50 years) have always “considered” themselves Acute Care Surgeons. They have a wide range of training and their practices often included at least some components of trauma, vascular, thoracic, advanced laparoscopic and endoscopic procedures as well as the management of patients in the ICU. Emergency care is a significant component of every rural practice and surgeons have historically provided emergency call 24/7, regardless of the hardships it wreaked on their personal lives. Most rural practices and hospitals did not (and still do not) have an organized acute care surgery “program”; the time required for the care of acutely injured or surgically ill patients is always at the expense of an elective, financially rewarding private practice or, and this is not to be discounted, family or free time. This generation of surgeons is perhaps an anachronism, the last holdouts to a historical organization of general surgical practice patterns. The burden of nocturnal call, covered by so few individuals, is now creating very real operational problems for hospitals and the patients they serve. There have been numerous lectures, meetings, scholarly papers, book chapters, and especially locker room philosophers discussing the social and historical reasons this comprehensive skill set and practice model has devolved. I will leave that to the experts to unpack, but one thing is

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

29

certain, while many smaller community programs still have the talent, they are now having difficulty fielding a team that can provide comprehensive acute care emergency general surgery twenty-four hours a day, seven days a week. One additional point cannot be ignored. Namely, practitioners and smaller hospitals have often had long term informal relationships for specialty care with regional tertiary care centers, which have been undermined in the last couple decades by new rules of competition, new business models, aggressive branding, and governmental mandates. This has had a negative effect on smaller institutions and their delivery of surgical care, especially in surgeon recruitment, retention of critical employees, and patient preferences. Unless one truly believes (and at least some do) that all surgical care needs to be done at large, tertiary centers, then practical strategies to address the emergency surgical needs in rural America are needed. Rural Hospitals are Acute Care Surgical Hospitals (or at least can be) I will submit that the concept of a hospital centric, Acute Care Surgical program offers a rational approach to provide timely and quality care for patients in their own community (ER to OR to ICU) with all the benefits that care close to home offers. It makes economic sense as well. Very few general surgery cases require tertiary care resources and technologies. Well-trained, motivated surgeons can do nearly any general surgery case in just about any hospital that has basic technology, good anesthesia support and nursing, and access to a real ICU. Nobody benefits from transferring patients to other facilities unless they can truly get something that cannot be provided on site. The transferring facility loses the revenue, the local surgeons lose operative experience and income, the patient and family are significantly inconvenienced, and patients that could be handled at the primary hospital often overcrowd the receiving hospital. LifePoint Health (NASDAQ:LPNT)TM is a publicly traded, for profit hospital corporation that operates 75 hospitals in 22 states. At the smaller LifePoint™Health Hospitals (<100 acute care beds), 30-40 % of hospital revenues come from the GI/General surgery service lines (and often both these lines are provided by general surgeons). (23) At the same time, many of these hospitals are having trouble recruiting, hiring, and retaining general surgeons. The geographical physician shortage is a very real phenomenon in

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

30

several markets. This recognition has led LifePoint™ to prioritize and facilitate the delivery of general surgical care in its many facets and has led to the development of a surgical support program aimed initially at providing relief to surgeons in their rural hospitals, especially for acute care.(24) This program has evolved and now is helping to support, as well as develop and implement, acute care programs at appropriate sites. These programs, foremost, allow the hospital to provide timely care to local patients around the clock. Secondly, they provide structure that delineates elective surgical practices from emergency care and, by doing so, have the potential to improve surgeon lifestyle. These programs often require financial support from general hospital revenues, which is provided as income to the physicians but also to hire additional medical ancillary staff, including physician extenders. Case Study: Wilson Regional Medical Center LifePoint™ Health, through its subsidiary Duke LifePointTM, acquired Wilson Regional Medical Center, a 264-bed hospital in 2015. Roughly half the beds are used in the care of acutely ill patients. As part of the acquisition, a fund for reimbursing physicians for uncompensated care was eliminated because of legal and compliance issues. In a strategy to replace those lost (and important) reimbursement funds, the local private surgical group, Wilson Surgical Associates, in a transparent and good faith agreement, contracted with the hospital, to create a structured, defined, hospital based acute surgical care program they termed “Acute Care Surgicalist”. This was very different from their previous private practice model. They provided an in-house surgeon who was available for rapid assessments and consultations and solidified relationships with the hospitalist program and emergency physicians and anesthesiology coverage, all of whom were also contracted by the hospital. The generalized effect has been largely viewed as positive. Major disruptions to the group’s private practice and, more importantly, delays in emergency surgical care, have been largely eliminated. The surgeons dedicate their week of acute care surgery to hospital work and are essentially unavailable in their office. On the other hand, when the surgeons are in their office, hospital issues do not interrupt them. The result has led to more efficient

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

31

use of elective block time for all the surgeons. Overall case volume for the practice went up 20% after implementation of the “Acute Care Surgicalist” program, as it is called. The more urgent cases are being done during the day in a designated acute care room by the “Surgicalist” with the full complement of OR staff. This has been a key component of the success, namely having the ability to “flex” a room during the day to get an urgent/emergent case done within one to two hours, rather than waiting until the elective schedule is complete and “adding it on”. A room is not “reserved”, like a full-on trauma room might be. There may be two or three rooms involved in the shuffling. The staff is motivated to get it done while the full component of staff is there to prevent backing up in the evening. There is a dedicated commitment to make an OR room happen ASAP for general surgical emergencies. As a result, after-hour add-on or emergency cases dropped by 47%.(25) The numbers of weekend and holiday cases have been, as expected, unchanged. Staffing the ORs has become more reasonable and less burdensome and all stakeholders have been pleasantly surprised by the new efficiencies. Case volumes went up, both emergent and elective. Block times were more effectively filled. The financial agreement between the hospital and group was straightforward. The surgeons have some production and performance-based measures that conferred a financial risk if they do not perform. The hospital essentially paid for the services (salary) of a FTE surgeon and allowed the surgeons keep their professional fees. Other less obvious benefits are becoming manifest. The group has historically had some difficulty recruiting and retaining young surgical talent in the traditional private practice model. They are now getting significant interest in their practice because of the Acute Care model as surgeons are increasingly interested in a more definable “shift” type of practice. The model is providing alternatives to retirement for the older members of the group who wish to slow down but not completely stop practicing. This implementation is only one iteration of the Acute Care Surgery model, but even in this simplified version, the advantages of the partnership and structure have become manifestly obvious.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

32

Nuts and Bolts The size of the hospital (number of medical and surgical beds) and traffic through the Emergency Room will ultimately determine the structure of its Acute Care program. In my experience, approximately 30,000 to 40,000 ER visits a year is the volume needed to support an organized acute care surgery program in a hospital. While lower volume of patients may not make an acute care surgery program financially profitable from the clinician’s professional receivables, it may still be advantageous to prevent the real risk of losing talented surgeons which can be devastating to the program and the hospital. Additionally, the physician expenses are only part of the balance sheet that needs to be considered. Any discussion regarding the formation of an acute care surgery program must be considered in light of its contribution margin to the hospital entity which can be readily measured. Finally, complex Stark law provisions make the legal ramification of this transaction much simpler if the surgical group is fully contracted by the hospital. Whether there is a commitment to trauma needs to be addressed in the context of the regional healthcare needs, as well as the familiarity of the hospital and surgeons with the care of traumatically injured patients. In any case, by creating a formal acute care surgery program structure, the “bones” for developing further programs such as a trauma program will be in place. The hospital in Wilson is busy enough with 36,000 ER visits/year to easily support a full-time ACS surgeon 7am to 5 pm Monday through Friday. Working as a team, the on-call surgeon for the night then takes over any pending cases or consults and hands it back to the ACS surgeon at 7 am. At this hospital, call is from home at night and weekends. They have not started using physician extenders in the ACS program yet but there is certainly room to add this resource that has the capability to make the surgeons more productive and efficient and free up even more personal time. The program that has been implemented at Wilson Regional hospital has the basic structure that can be applied in almost any hospital site. We are currently working towards implementation of ACS programs in several other LifePoint™ facilities. Again, it is a matter of partnership, commitment, and the strategic use of resources.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

33

Conclusion Rural and smaller community hospitals often lack the resources and subspecialists of larger hospital systems. Most importantly, the old practice model in which a couple of general surgeons covered the emergency needs of a hospital 24 hours a day, seven days a week is becoming increasingly rare. As a result, the ability of such facilities to provide urgent surgical services has diminished, with many adverse consequences. A formal Acute Care General Surgery program is clearly a service that can be offered to provide comprehensive emergency surgical care to these communities. It requires a formal agreement and working relationship between surgeons and their hospitals and an organizational structure to provide the service. It requires financial commitment from the hospital and professional commitment from the surgeons but the potential payoff is obtainable and easily measurable. Each situation will have its own nuances and unique needs and there will always be some customization needed. One size does not necessarily fit all. However, once surgeons and hospital administrators recognize the benefits of a partnership and the ACS structure for the delivery of acute care, the program can move forward. Perhaps more importantly, if these real needs are not addressed, hospitals, patients, and surgeons will all suffer the consequences

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

34

Acute Care Surgery in Academic Medical Centers Joseph M. Galante, MD FACS Introduction Acute Care Surgery (ACS) is not emergency general surgery, it is the combination of trauma, emergency general surgery and surgical critical care. The acute care surgeon has the ability to care for the emergency surgical patient from the emergency department through discharge without requiring any medical hospitalist or medical intensivist assistance. This concept is most evident at academic medical centers with trauma designation within the United States, and it has been expanding around the world. Acute Care Surgery was developed to address the inadequacy of emergency surgery coverage for patients who do not present with in a schedule, elective fashion, but rather present with emergency surgical needs any time of the day. In addition to the emergent nature of the patients, they often have little or no insurance, do not have routine primary medical care home, and have several untreated or unrecognized comorbid conditions. Gale and colleagues documented this reality, noting that at a level 1 trauma center in New Jersey, the patients presenting to emergency departments had more comorbidities and lacked insurance compared to patients going to community hospitals.(26) Due to the unpredictability of emergency services with respect to patient volumes, times of presentation, and severity of illness, an ACS service has many unique organizational and operational demands compared to other subspecialty surgical services within the academic medical center. The purpose of this chapter is to describe the components of an academic ACS service, provide an example of a model used in the academic setting, discuss how this service impacts patient care and identify challenges encountered by the ACS service model. Organization and Operational Structure The organization and operational structure of the ACS service in any academic medical center has some common components. The ACS service must provide 24 hours a day, 7 days a week, coverage of all emergency general surgical patients in the emergency department and the hospital. Having a dedicated service provides the system with a single

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

35

“go to” surgical team for any surgical consultations and emergencies. The primary consulting team does not have to call multiple surgical specialists to find a surgeon who can take care of the patient’s immediate problem. More importantly, the ACS service is dedicated to this emergency patient population, free from other overlapping and competing commitments such as outpatient or elective surgeries. (27) Precluding elective surgery during ACS call does not prohibit the surgeon from having an elective practice outside of the ACS service. The ability to have an elective practice depends on the number of ACS surgeons at the institution, the number needed to cover call, the surgeon’s interests, available time outside of ACS service and academic pursuits, and the workflow of the entire department of surgery. The ACS surgeon is only a “part-time elective” general surgeon because the practice of the ACS surgeon has evolved into a distinct specialty. (27) The ACS surgeon has distinct expertise to be seeing all the urgent and emergency consultations. That expertise extends beyond surgical management and includes critical care management. In 2008, the American Association for the Surgery of Trauma (AAST) established the first fellowship in ACS. The curricula for the fellowships reflect the type of surgical disease seen in ACS practice, including surgical critical care. (28) Twenty-four-hour coverage is a common element for the ACS model but it does create some challenges. The patient care needs of a typical ACS service include the ICU, the trauma patients, the emergency non-trauma patients, and in-hospital consults for surgical needs. The staffing requirements of a busy ACS service in an academic trauma center often require at least two or three attending surgeons per day with no more than every third night call. (Figure 1) Attending bedside coverage may need to be provided by separate and distinct surgeons for trauma, emergency general surgery, and surgical critical care. Most centers try to provide this separate level of coverage during working daytime hours, but often limit the number of acute car surgeons in-house or on-call to only one or two surgeons, yet the busiest hours may well be from 4 pm to 2 am. Avoiding burnout for the ACS surgeon is one of the key elements of sustaining this practice model. The department leadership also needs to account for the academic career of these surgeons, which requires

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

36

time for research and attendance at national meetings. These issues increase the number of surgeons required to staff the service, and all depend on the volume of clinical needs. The Society of Critical Care Medicine has suggested patient to physician ratios greater than 14:1 negatively impact the perception of care and ratios greater than 15:1 increase ICU LOS.(29) The ratio of 14:1 has been identified as acceptable for internal medicine residents at the Mayo Clinical with respect to duty hours and workload.(30) To date, there are not well-accepted and published data on the volume of patients that should be attended by any one surgeon. One common element with patient to physician ratios is the impact of workload on physician burnout. Trauma surgeons, more hours worked per week and more night calls per week increase the risk of physician burnout. These factors must be accounted for when designing the academic ACS service.(31) Patient care demands that the ACS surgeon must be dedicated in time and commitments to the patient group (service) designed by the institution. Namely, and as an example, the Acute Care Surgery attending cannot be responsible for meeting the needs of the Emergency Department for surgical consults, while at the same time be responsible for patient care in the ICU, nor to run an elective patient care clinic, and so on. The surgeon needs to be unencumbered to see and perform surgery for all emergency and urgent consultations, as well as care for patients who are already on the service. This excludes the surgeon on the ACS service from conducting an elective clinic or elective operations, or for the most part, administrative meetings, at the same time as being on ACS. The ACS surgeon cannot maintain an elective surgery schedule while on ACS service. Both the emergency and elective patient groups have the expectations that their surgeon is dedicated to their care. Balancing the elective case with the emergency case is not feasible in the modern academic medical center. The stressors placed upon the surgeon when having to shift from case to case, ICU to emergency department to ward, can be overwhelming when elective patients are factored into the mix. Paying for this service often must be part of the hospital’s responsibility, as non-operative care simply cannot generate the amount of reimbursement that will support an acute care surgeon’s salary. Yet the attending surgeon is needed to keep these vital services of the hospital open and running, can significantly influence patient care and efficiency of care.(32, 33)

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

37

Depending on the volume of trauma at the academic medical center, the ACS surgeon may be able to cover both trauma call and emergency general surgery call. Indicators that this is too much of a dual responsibility would be long delays for surgical consults in the hospital or the ED, longer lengths of stay in the ED and hospital, and delays in meeting benchmarks for the performance of urgent and emergent operations.(34, 35) The workflow for trauma with the fluctuations in volumes and unpredictability, mirror ACS. Trauma also offers a similar framework of care as ACS. Patients are often critically ill and seen in the emergency department, they go to the operating room, then ICU and finally ward before being discharged. The hospital or health care system’s approach to emergency general surgery relies upon a similar framework to trauma, namely the need for robust multidisciplinary collaboration an active and empowered performance improvement activity. (Figure 2) Like the trauma program, the entire ACS program needs to cross disciplines, not only for medical and surgical specialties, but also ancillary staff. These programs rely upon developing relationships that seamlessly integrate other specialists into the care of the injured and acutely ill. Relationships with other specialists, such as gastroenterology, surgical oncology, and cardiology, are essential to an ACS service. In trauma programs, one of the challenges is to encourage and mandate that consultants to follow trauma-specific guidelines and attend trauma process improvement conferences. The same applies to ACS. As an example, how do you get the gastroenterologist to promptly perform the ERCP decompression of a patient with cholangitis? In trauma, the trauma program often has the backing of the American College of Surgeons or the commitment of the hospital to be a trauma center. That commitment lends some weight to the program when one approaches a subspecialist. Currently, both the American College of Surgeons and the American Association for the Surgery of Trauma are actively engaged in developing just such guidelines for emergency general surgery. Having the support of the hospital may not be enough. The real ability to affect change in physicians is the ability to bring relevant and robust data to support the guideline and protocol as patient care improvements. The same applies to acute care surgery. Robust and relevant data needs to be collected and used to affect change in practice patterns.

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

38

Having the outcome data is the first step in moving the collaborative effort forward with ACS related subspecialists. The acute care surgeon model has some distinct advantages in an academic medical center setting for not only the patient, but also for the surgeons. Acute care surgery converts a largely non-operative specialty care of trauma surgery into a much greater operative experience.(36, 37) This enhanced operative volume from an ACS practice improves trauma surgeons’ operative experience and their job satisfaction. The service also offers a great variety to practice, and is perhaps the only general surgery specialty (along with cardiac surgery) where critical care is a central component of practice. The patient population encountered through ACS is often critically ill. These critical care surgeons have a clear understanding of the interaction of surgical pathophysiology with the patient’s underlying medical conditions. Having a surgeon caring for them with a qualification in surgical critical care is an added benefit.(38) The ACS service can provide all care thereby eliminating the handoffs between surgeons and intensivists. This is better for continuity of care and facilitates an improved performance improvement process. Research and investigational opportunities abound on the ACS service. These range from the most basic science areas of human genome and precision medicine to clinical outcomes to improving efficiency and process of care and the finances of medicine. Additionally, trauma is a core component of essential health care in developing nations, and the opportunities for global care are evident. The Acute Care Surgery service in an academic medical center needs to be actively engaged in advancing our knowledge of how best to care for this patient population. Having a similar group of surgeons caring for a disease entity also lends itself to more robust clinical trials and studies for any particular disease.(28) The diverse practice of ACS offers a vast amount of resident education opportunities.(28) The ACS surgeon is familiar and comfortable dealing with emergencies, sometime more so than the surgical subspecialist. This comfort level enables them to take time to teach during the emergency cases.(39) The diversity of practice and high pace flow is attractive to today’s surgical resident and demonstrates to them that this is an attractive,

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

39

viable, and sustainable career option with excellent work-life balance opportunities and a wide arrange of pathophysiology.(37, 40) Global Models ACS is not limited to the United States. The model has begun propagating across the globe.(38) Each hospital around the world has its own idiosyncrasies but the common themes of organization and operations stay constant. Table 1 illustrates the common themes seen in ACS models used around the world. The international models have developed with similar attributes as the US model in academic medical centers. The international ACS models have impacted patient care regardless of location. At the University of Alberta, Lim et al. reported that preoperative delays were reduced by 10 hours with the establishment of a dedicated ACS surgery team with dedicated OR resources.(41) The ACS model in New Zealand has shown improvements with decreased length of stay and an increase in number of operations completed during the daytime hours for appendicitis.(42) In the US, similar results have been seen with ACS models. Madore et al. showed that the ACS model had significantly more laparoscopic appendectomies versus open when compared to on call general surgeons.(43) Cubas et al. published a study comparing ACS to traditional practice and found less complications, a shorter time to OR, and decreased length of stay with the ACS model in appendicitis.(44) The authors of many of these studies attribute the success of the ACS model to several factors, but the most important are a dedicated surgeon available 24 hours per day and allotted hospital resources for emergency surgery. Challenges The implementation of the ACS model in academic centers is not without challenges. These challenges center more on the patient population being served by the ACS service at academic medical centers, and not on the service organization or daily functioning. The main challenge is caring for a large population of under- or uninsured, with minimal or no primary medical care, or no “medical home”. As implied by Gale et al., the patient

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

40

populations seen by academic ACS services are similar to the urban trauma population. (26) They are sicker when they present to the hospital and have more untreated comorbidities. This combination dictates that these patients require more ICU resources.(45) It has been observed that the academic ACS service model provides some distinct advantages of critical care rescue, and experience in caring for these critically ill patients. As an example, the outcomes for diverticulitis were equivalent when compared between Level 1 academic medical centers with sicker patients and community hospitals with less ill patients. A second challenge is how to care for the patient population who does not need an operation during the hospitalization. How does one transfer the care to the appropriate specialist or how does one get a patient who is uninsured or under-insured into follow up in an outpatient setting? The solution for these circumstances is more complicated, but can be approached in a manner similar to how trauma orthopedic surgeons care for patients who need to wait for their surgical repairs. Depending on the local circumstances, the orthopedic surgeons may have arrangements with medicine to accept the patients onto their service until optimized, develop relationships to send the patient to another acute or rehab facility to wait for surgery, institute a plan with the insurance provider and bring the patient back later from home, or the least optimal, keep the patient in the hospital until surgery. Finally, financial viability of the service is a challenge, especially with an underinsured patient population. Ciesla and colleagues highlighted this by showing that the patient revenue alone does not cover the expenses to run an ACS service.(46) They have advocated for outside supplement by two sources, either the department of surgery or hospital. The Department of Surgery may be inclined to provide a subsidy to offload the department’s surgical subspecialists from overnight emergency call. This enables the subspecialist to be well rested for their elective case schedule, but this money comes from the clinical income generated by these elective surgeons. The hospital is another and more likely source, because like trauma, ACS is a critical service provided for the hospital. ACS helps facilitate throughput in the ED and provides a surgical safety net for inpatients that develop surgical emergencies. The ACS surgeon is the most senior attending physician in

Acute Care Surgery: An Evolving Paradigm

Jurkovich & Davis

Page

41

the hospital at all hours, and can be operating on weekend and in the evenings to help offload the OR. Surgeon

Senior Surgeon Onsite Day Offsite Night No Elective Cases

Acute Care Surgeon On call Onsite 16:3017:30 No Elective Cases Change at night 1630-1730 2 Surgeons Ward Rounds

1 Surgeon All emergencies Admissions Consult

Acute Care Surgeon on site 0700-1600 No elective cases Acute Care Surgeon on call for ACS/Trauma 16000700

Conclusion Acute Care Surgery practice paradigm has matured since it was first formalized by the AAST in 2005.(9) It has been adopted into the existing framework of many academic surgery departments in the US and around the world. Seamless integration of ACS in the department of surgery has allowed the departments of surgery to better meet their overall goals. ACS provides a service of high quality patient care to vulnerable populations. This care involves a vast array of surgical disease processes and requires the surgeon to be facile in many different types of operations. The diversity and urgent nature of ACS provides an opportunity to educate residents in broad topics of general surgery. The ACS faculty has a pathway towards academic promotion through teaching and research. Finally, the ACS service can be the foundation for the department of surgery by freeing the other subspecialists from emergency department call to focus on elective practices and disease specific consultations.

Table 1 (Chapter VI): ACS Faculty Covering EGS and Surgical Critical Care in Four Countries United Kingdom(27)New Zealand(42) Sweden(47)

United States

Acute Care Surgery: An Evolving Paradigm

Hospital Resource

Additional Staffing Needs

Transitions of Care

Jurkovich & Davis

24 hour OR Dedicated OR

+/- Registrars (Surgical Residents)

Dedicated Resident 1 Midlevel Provider

Dedicated OR (shared with OB/GYN) 2 Acute Care wards 1 outpatient clinic 2x/week

3-4 Senior Residents (+ 1-3 junior) Night coverage (resident in house covered by subspecialized gen surgeon)

Page

42

Dedicated ACS OR + Trauma room

Senior resident, mid-level resident, 3 interns, Midlevel provider and cross cover residents

Morning report sign out Refer to sub-specialist

Refer to Specialists 3 Handoffs per day

Patient Benefits from Acute Care Surgery Service Bellal Joseph, MD, Viraj Pandit, MD In recent years, there has been a paradigm shift in the health care system in the U.S., especially in regards to the care of emergency surgery patients. Taking care of these patients requires emergent surgeon access, surgical intervention, a fundamental function of a hospital and an emergency department. An absence of high-quality emergent surgical care, however, remains a growing problem across the country.(48) Multiple factors underlie this problem, including a shortage of surgeons, increasing numbers of uninsured patients, and lifestyle considerations. (49) Additionally, the increasing trend towards sub-specialization by general surgeons makes it more difficult to provide expert care for emergency cases that fall outside the realm of a surgeon's specialty.(4) Consequently, it is increasingly difficult for hospitals to provide generalsurgery-call coverage for such emergent cases. Given the increasing specialization

among surgical specialties as well as changing reimbursements, surgeons are also increasingly opting for elective schedules and clinics, exacerbating the increasing void in coverage for emergency surgeries.(50) In fact, trauma surgeons have been functioning as emergency surgeons simply because they are readily available for managing emergent trauma patients. However, variability in the volume of trauma cases in different centers and across the seasons as well as advances in the non-operative management of many trauma cases has resulted in trauma surgeons having long working hours and lower reimbursements, while undertaking very few surgical procedures.(51) Naturally enough, all of this has resulted in a declining interest among general surgeons in the practice of trauma care. Inevitably, the acute care surgery (ACS) model arose as an effective and resourceful way to boost interest in trauma surgery as well as to increase the availability of emergency surgical care and operative experience. Indeed, the ACS model has provided efficient and effective emergency, general surgery care for hospital patients, and it has given trauma surgeons more operative experience. As this model of surgical management has spread across the U.S., it has also resulted in the establishment of fellowship and training courses that instruct future ACS surgeons in emergency surgery, trauma, and critical care. Subsequently, ACS became a distinct way to urgently assess and treat adult patients with general surgical emergencies. It addresses a diverse range of disorders that often entail unique diagnostic and therapeutic challenges for caregivers.(52) Furthermore, trauma surgeons became the backbone of the ACS model because patients who are in need of emergency surgery are acutely ill and can pose diagnostic dilemmas that often require an expertise in aggressive resuscitation, critical care, and emergent interventions. In this section, we will review a number of studies that show how patients benefit from an ACS service as well as how it leads to more efficient hospital utilization of resource. (53) We focus on commonly managed and treated emergency surgical problems. Acute Cholecystitis

Acute cholecystitis is the most common cause for emergency hospitalization among patients in the U.S. There is evidence that an early cholecystectomy in patients presenting with acute cholecystitis provides the best value in health care. In a large, randomized control trial, for instance, an early cholecystectomy performed within 24 hours of presentation was associated with better outcomes than a delayed cholecystectomy.(54) More specifically, these studies show that an early cholecystectomy in patients presenting with acute cholecystitis is associated with significantly reduced laparoscopic-to-open conversion rate, post-operative complications, and hospital length of stay. (55) The ACS model was introduced to decrease the disruption of elective cases, improve operative resource utilization, and decrease unnecessary out-of-hours operating. Prior to this, non-trauma patients in need of semi-urgent, emergency surgery had to wait for the general surgeons on call, which frequently delayed the procedure and disrupted the elective surgery schedule. In contrast, an ACS service allows around-the-clock patient care and delivery care for patients presenting with acute cholecystitis by providing an operating room that is dedicated to such urgent cases.(44) Providing timely patient treatment has resulted in a shorter length of stay, less resource use, lower complication rates, and a significant reduction in hospital costs. It does appear to be associated with an increase in operative time, perhaps due to the need to have residents supervised.(56). In the current era of increasing financial pressure, it is also important to highlight that an ACS service also optimizes the use of available resources.(57) Moreover, following the success of ACS in the U.S., it has spread to other countries where its advantages have been further validated, specifically regarding the improvement of patient care, a reduction in complications, and cost savings.(56-58) Even elderly patients with acute cholecystitis (and for whom a much-needed cholecystectomy was routinely delayed due to their baseline comorbidities and medications) has improved outcomes when trauma surgeons head up their management and perform emergency cholecystectomies. Clearly, the ACS model works effectively for cholecystectomies as it benefits patients, hospitals, and surgeons. (58) Acute Appendicitis

Acute appendicitis is one of the most common causes of abdominal pain in emergency room patients. Appendicitis is primarily a disease of younger age groups, with only 5-10% of cases occurring amongst the elderly. However, the elderly suffer greater complications from appendicitis.(59, 60) Consequently, because of this as well as delayed and atypical presentation of appendicitis in the elderly, a high index of suspicion and early operation are important in order to avoid complications like perforation and subsequent morbidity. (61) Appendectomy is one of the cornerstone operations of general surgery. More than 300,000 appendectomies are performed annually in the U.S.(62) Appendicitis patients can present at any time, day or night, and delays in operative intervention can result in complications. Although appendectomy is generally well tolerated by most patients, it is a major surgical intervention and can be associated with postoperative morbidity..(62) Additionally, a patient with complicated appendicitis can be challenging, time-consuming, and disruptive to an elective general surgery practice. Though, a study by Earley et al. has shown that patients with acute appendicitis presenting at hospitals with ACS have shorter wait times before surgery.(63) Moreover, they also found that the management of appendicitis by an ACS service is associated with reduced perforation rates and complications, as well as a significant reduction in the hospital length of stay compared to a general surgery service. Following the implementation of ACS service in an academic department of surgery, Britt et al. found that it increased productivity by increasing the use of a daytime operating room as well as by providing a wider base of consultative and operative experience to the participating academic surgeons and trainees.(53) Similarly, after initiating an attending in-house ACS model, The University of Pennsylvania School of Medicine found a significant improvement in time to operation, rupture rate, complication rate, and hospital length of stay.(63) They showed that the presence of in-house surgeons plays a significant role in decreasing the time from surgical consultation to operative intervention. In the ACS model, for example, there should be fewer delays simply to more prompt attending surgeon presence. Interestingly, they also found out that the actual presence of an in-house surgeon seemed to be more important than the extent of the surgeon’s experience. In fact,

outcomes were better in the ACS model, despite 70% of the operations being performed by surgeons with less than 5 years of experience. Even in case of acute appendicitis, evidence demonstrates that the ACS model allows for more efficient resource utilization and more satisfied patients, primarily due to the relatively swift care of medical emergencies. These benefits of ACS will become even more obvious as the population ages and surgeons successfully tackle more surgical emergencies involving patients with multiple comorbidities and active medical problems. In other words, given the wide demographic spectrum of patients with complex disease processes, trauma surgeons are ideally suited to leading an ACS team to improve patient care and outcomes. Small Bowel Obstruction Along with the overall increase in surgical procedures being undertaken, there has been an increase in the number of patients with a small bowel obstruction (SBO) presenting to emergency departments. The acute management of these patients is critical as they require active resuscitation to compensate for fluid and electrolyte shifts, secondary emesis, and poor oral intake. In recent years, there has been a shift in the care of obstructed patients towards more conservative, non-operative management. The implementation of the ACS model has played a critical role in this transformation. The training and experience of trauma surgeons in complex fluid and blood resuscitation strategies was conducive to the employment of early and aggressive resuscitation strategies in patients with bowel obstruction. This, in turn, helped improve the success rate of non-operative measures and the outcomes of patients requiring surgical intervention. Furthermore, the availability of an in-house surgeon, around the clock, guaranteed reliable serial clinical examinations of patients managed conservatively as well as timely surgical interventions in the case of clinical deterioration. It is no coincidence that all the evidence supporting conservative, nonoperative management in the case of an SBO comes from centers with a robust ACS service caring for such patients.(57) Likewise, in patients undergoing surgical intervention evidence indicates that the application of the ACS model to results in shortened preoperative time, a reduced hospital length of stay, and a higher discharge

rate. Again, the ACS model plainly improves the quality of care of patients by enhancing the appropriate timeliness of care and resource utilization.(64) As stated earlier, with the ACS model, patients experience decreased mortality, morbidity, and length of the pre- and postoperative stay in the hospital.(65) Acute Diverticulitis Diverticular disease is a common disorder that results in 312,000 hospital admissions and 1.5 million days of inpatient care every year in the U.S. In the developed world, approximately half of all individuals over the age of 50 have colonic diverticulosis. This proportion increases to 70% by the age of 80 years.(66) The majority of patients with diverticulosis (approximately 75%) are asymptomatic. The spectrum of diverticulitis disease ranges from: uncomplicated (which is routinely managed as outpatient care), complicated (with micro-perforation that requires admission with IV antibiotics, and severe diverticulitis (with frank perforation peritonitis and fecal contamination that requires emergency surgical intervention). This popular, severity-based management practice is known as the “Hinchey” classification, a 1978 classification system modeled after an early 1963 publication by Hughes (67, 68) Hinchey system grades patients with diverticulitis from I to IV; surgical interventions are then tailored to the severity of the disease. Antibiotics alone for Grade I disease, laparoscopic washout (or open washout)for grade II or perhaps grade III, and resection of affected segments of the colon (with anastomosis) in a minority of cases and an end-colostomy in the majority of patients with Grade IV disease.(69) The role of an ACS system is especially critical in this subset of patients with diverticulitis who require urgent intervention, although there is of yet little publications assessing the impact ACS model on patient outcomes. Nonetheless, the evolution of the ACS model has helped advance the surgical management of patients with acute diverticulitis. In summary, the ACS model is extremely beneficial and effective from the point of view of the patient, the surgeon, and the hospital. It provides efficient patient care that improves outcomes as well as patient satisfaction. It is economically beneficial to hospitals because it reduces the hospital length of stay and the overall cost. It also improves surgeon satisfaction because interns help provide better care. In short, this

model epitomizes “value” in health care, meaning better outcomes at lower costs. The ACS model of surgery is likely to continue to evolve, with a key feature of this evolution being the development of guidelines and standardization of resources needed to provide optimal acute care surgery.(70) In fact, the development of an “optimal resources” guide for acute care surgery is a current project of the American Association for the Surgery of Trauma, the founder of the ACS training program. This current curriculum for acute care surgery encompasses the training of surgical investigators who will likely drive this next phase of acute care surgery.

The Future of Acute Care Surgery Robert D. Becher, MD MS & Kimberly A. Davis, MD MBA The creation of Acute Care Surgery (ACS) as a training and practice paradigm was driven by a lack of surgeons available to take emergency call and thereby resulting in poor access to emergency surgical care across the United States. Creation of ACS services allow the time-critical delivery of urgent and emergent surgical care in an era of surgeon workforce shortage, specifically by identifying a surgical specialty of the practice of critical care, trauma and advanced emergency general surgery procedures. The field is attractive for its diversity of career options, and its tremendous benefits to society. Many of the initial concerns regarding the implementation of this model and introduction of this fellowship training programs have not come to fruition. Specifically, resident education and non-trauma surgeons’ operative logs have not been negatively impacted. In addition, the most critically ill surgical patients have benefited with improved outcomes, more efficient care, and decreased mortality. (4, 71) Just as the needs of the injured patient drove the development of the field of trauma surgery, so are the needs of the emergency general surgery patient driving the development of the acute care surgery paradigm. The training paradigm for the ACS fellows will continue to ensure that fully trained acute care surgeons are comfortable with a wide variety of anatomic exposures across all body regions. Acute care surgeons are uniquely positioned to impact health care cost containment and improve care in the United States as mandated by the Affordable Care Act of 2010. Cost savings can be actualized, and the system for care delivery can be optimized by focusing on throughput and the use of standardized, evidence-based, consistent care. Acute care surgeons stand at the front line of care delivery for the patients who are most critically ill and for the injured surgical patients with time-sensitive diseases. Getting the right patient to the right venue at the right time is the paramount skill that the acute care surgeon, through training and experience, adds to the value equation. (72)

The further promulgation of the acute care surgery paradigm will require a thoughtful approach. Issues that will need to be addressed include: further augmentation of the ACS workforce through training program promulgation and ongoing trainee recruitment; development of a resource to guide program and service development, similar to the Resources for Optimal Care developed by the American College of Surgeons Committee on Trauma for trauma center verification (www.facs.org); development and promulgation of best practice guidelines; and a research agenda focused on basic and clinical science, as well as patient outcomes and care system development. Augmenting the Acute Care Surgery Workforce: A survey of all graduates of approved AAST fellowship programs demonstrated that most graduates practice acute care surgery in teaching hospitals designated at Level I and Level II trauma centers. Overwhelmingly, the fellows reported that the fellowship added value and prepared them well for practice. (8) As interest in ACS as a specialty practice paradigm and as a training program grows, it is hoped that more academic medical centers with mature ACS services will be applying for approved fellowship positions, at a rate of approximately two to three programs per year. The pace at which programs are embracing the training paradigm is accelerating, and may be related to the increasing number of fellowship trained physicians working in these programs. The effect of positive mentorship on attracting trainees to the field cannot be under-estimated and should be strongly encouraged. In April of 2016, the American Board of Surgery (ABS) released a statement regarding residency redesign which envisions a new paradigm for general surgery training, with the stated goal of greater autonomy and flexibility for the trainees.(73) In this document, the ABS proposed a “core plus” framework, which would consist of a core four years of general surgery training, followed by a variable number (1 to 3) additional years of focused specialty training. The idea driving this consideration is that with a highly structured training model, with clear and measured performance hurdles, core general surgery could be accomplished in four years, but that everyone would need some additional training in a “specialty area” of choice. In many ways, this is

similar to the current paradigm of five years of general surgery, followed by one to two years of “fellowship”. Currently 80% of graduates of a five-year general surgery training program participate in some subsequent training, about one-half in programs verified or approved by the ACGME (Accreditation Council for Graduate Medical Education), and the other one-half sponsored by specialty societies, like the AAST and its Acute Care Surgery fellowship.(73) The more unique feature of this new proposal is that everyone would have to accomplish the “plus” years of training, including an as yet undefined “advanced general surgery fellowship”. Several unanswered questions persist regarding the statement released. Chief among these include how the ACGME and surgical residency review committee (RRC) view the proposed changes, as all general surgery training and 50% of fellowship training currently fall under the aegis of the ACGME and RRC, and not the American Board of Surgery. Certainly, not all program could support all “plus years”, and some may not be convinced of the utility of this approach and view it as the end of “general surgery” in the United States. Further questions involve the future mechanisms for oversight of the many non-ACGME fellowships, like Acute Care Surgery. Will they remain under the supervision of the specialty societies who supported their creation, like the AAST, or will they be encompassed into a more formal ACGME-like training paradigm? Until these questions are more formally and completely addressed, the question of whether ACS training will become an ABS certified specialty will remain unanswered. Current certification for those completing approved fellowships is provided by the AAST. However, having the specialty formally recognized by the American Board of Surgery would likely augment recruitment to the field. Twenty years after the inception of the Acute Care Surgery fellowship, there are 21 approved fellowship training sites. Many of these programs train one fellow per year, although several train more than one fellow per year. Many academic, universitybased trauma programs have ample patient volume to support a training program but have yet to adopt the ACS training paradigm. The perceived competition between learners, including subspecialty fellows and senior surgical residents, may be a reason why some of these programs have not embraced the ACS fellowship model. Others may still ascribe to the belief that a well-trained general surgery resident who has also

completed an ACGME approved surgical critical care fellowship is adequately trained to provide the breadth of services required of most practicing acute care surgeons. However, to address the needs of the most critically ill surgical patients in the future, it will be necessary to augment not only the number of training programs, but also the number of trainees per program, to meet the growing needs for emergency general surgery coverage. Identification of resources for the optimal care of critically ill general surgical patients: In 1976, the American College of Surgeons Committee on Trauma released an optimal resource document focused on improving the care of injured patients, and based on the belief that trauma is a surgical disease demanding surgical leadership. Within the document, and all its subsequent revisions, are guidelines as to how to address the needs of the injured patient, regardless of where they receive care. The most recent version (2014) emphasizes the delivery of optimal care, in a cost-effective manner, and focuses on the cooperation of institutions within a trauma system to achieve this goal. Such systems of care for the management of emergency general surgery patients are in their infancy. While it is well recognized that most straightforward emergency and urgent general surgery can be addressed at any institution with surgical capabilities, there is likely a subset of critically ill, physiologically challenged emergency general surgery patients that would benefit from care by surgeon trained in surgical critical care and/or acute care surgery. A vast majority of emergent surgical patients are managed at institutions without fellowship-trained acute care surgeons. Surgical emergencies are often addressed by “on call” surgeons with varied backgrounds, including the spectrum and variety of general surgery subspecialties. Such a divergent, variegated system of managing this unique, physiologically abnormal patientpopulation results in delays in care, practice variation, and disparate outcomes.(74, 75) To optimize outcomes following emergency general surgery in the subset of patients with physiologic derangement, a document like the Resources for Optimal Care of the Trauma patient will need to be developed.

Best practice guideline development: While there exist many best practice guidelines for two components of acute care surgery, trauma and surgical critical care, there are few directed at complex urgent and emergent general surgery. Well-known for its practice management guidelines for trauma, the Eastern Association for the Surgery of Trauma has begun to create practice management guidelines for emergency general surgery. Three such guidelines are currently available on the EAST website (www.east.org), covering the topics of Clostridium difficile associated disease, small bowel obstruction and colonic obstruction. The AAST has focused on developing grading systems for many acute general surgical diseases, like the grading systems developed for trauma care.(76) A grading system allows for specific management guidelines to be defined across a spectrum of disease. Recognizing that quality is driven by decreasing variability in practice, such guidelines and grading systems are important to begin to standardize care. Acute Care Surgery research agenda: Acute care surgery is a broad, all-encompassing term, which refers to a practice paradigm that includes the management of acutely ill patients with a variety of conditions, including trauma, burns, general surgery emergencies, and surgical critical care. While trauma and surgical critical care have a long-standing record of clinical, basic science and outcomes research, emergency general surgery (EGS) research is in its infancy. Emergency general surgery (EGS) is a massive public health problem. The incidence and prevalence of EGS conditions far exceed that of many common, highly publicized and studied public health problems, such as new-onset diabetes mellitus and newly diagnosed cancers (Figure 1). (26) EGS represents illnesses of very diverse pathology related only by their urgent nature. And more than 3 million patients are admitted annually to US hospitals emergently or urgently with emergency surgical problems; more than a quarter of EGS patients require surgery during their index admission.

A research agenda will need to focus on both the outcomes of care provided and on the pathophysiology driving the underlying disease processes. As many of the diseases encountered by ACS surgeons are inflammatory and/or infectious in nature, there is an opportunity to direct basic science and translational research towards the mitigation of the effects of infection and sepsis. Early work in the treatment of necrotizing soft tissue infection, and the promising outcomes of early clinical trials may serve as a template for further investigations going forward.(77) Leadership and Research Support The future of ACS as a surgical discipline is being well supportive by progressive leadership from three surgical organizations: the American Association for the Surgery of Trauma (AAST), the Eastern Association for the Surgery of Trauma (EAST), and the American College of Surgeons. The AAST redefined trauma surgery into acute care surgery 12 years ago, and are building the infrastructure necessary to train fellows and perform research in this field. The Acute Care Surgery Committee of the AAST has developed the educational paradigm for fellowship training, and promotes EGS-based outcomes research. EAST has formed an Emergency General Surgery Section for Professional Development in part to “encourage research endeavors into…emergent general surgical conditions” as well as an Emergency General Surgery Task Force committed to creating evidence-based EGS guidelines for patient care. The American College of Surgeons has for many years been a leader in outcomes research, highlighted by the advent of the National Surgery Quality Improvement Program (NSQIP) (https://www.facs.org/quality-programs/acs-nsqip). This expertise has been extended to EGS, with the recent creation of the EGS NSQIP. This database is the first national EGS registry to capture both operatively and non-operatively managed patients. High-quality data registries allow for identification of trends in management, and improvements in surgical outcomes over time. Trauma registries, such as the NTDB (National Trauma Data Bank), exist at verified trauma centers in the US for research, clinical documentation, and quality control purposes. And the Trauma Quality Improvement Program (TQIP) uses NTDB-collected data to provide risk-adjusted mortality and morbidity analysis of participating trauma centers to track outcomes and

improve patient care (http://www.facs.org/trauma/ntdb/tqip). The more accurate the data, the better the analyses, and in turn the more valid the statistical conclusions. These registries therefore have rigorous data collection methodologies outlined in detailed data-dictionaries, and have been validated through inter- and intra-coder agreement analysis to further ensure the quality of data collection.(78) Leaders in the field of ACS are moving to address the need for quality, comprehensive data focused on emergency general surgery patients. Work is underway to create a national EGS data-dictionary, and a pilot project has been conducted for an EGS registry modelled after NSQIP. (79) If structured as a consecutive-capture dataset (as opposed to one that only samples patients) that includes both operatively and nonoperatively managed patients, then this database has the potential to provide the field of EGS a powerful, risk-adjusted, prospective tool for EGS research. The EGS registry should also allow for considerable room for growth and advancement in the database’s ability to predict myriad potential outcomes in EGS patients, such as appropriateness of care, cost-utility, patient-reported outcomes, satisfaction with care, functionality, and comparative effectiveness. (75, 80) Conclusions: As the field of Acute Care Surgery continues to mature, delivery of optimal patient care remains of paramount importance. The surgical community needs to assure that there are well-trained clinicians to provide care to patients with time sensitive, critical surgical disease. To do this, clinicians need to be provided with an armamentarium of best practice guidelines, and research not only into the treatment of the underlying pathophysiology but in determining the best outcomes for the patient. Surgical leadership across multiple organizations are focusing their efforts on providing these data to clinicians.

Gale SC, Shafi S, Dombrovskiy VY, Arumugam D, Crystal JS. “The public health burden of emergency general surgery in the United States: A 10-year analysis of the Nationwide Inpatient Sample 2001-2010. J Trauma Acute Care Surg 2014;77:202-208 Figure 1 (Chapter VIII)

Ogola GO, Shafi S. “Cost of specific emergency general surgery diseases and factors associated with high-cost patients.” J Trauma Acute Care Surg. 2016; 80: 265–271 Figure 2 (Chapter VIII)

The future of Acute Care Surgery Analysis of the Rhode Island Hospital NSQIP database determined that there exists a greater than 10% failure-to-rescue rate in the surgical population. Twenty percent of the patients with the greatest risk for developing postoperative complications account for approximately 90% of failure to rescue. With complications of medical or surgical care being one of the most frequent hospital-based diagnoses (exceeding even cholecystitis, intestinal obstruction, and appendicitis), Acute Care Surgery, undoubtedly, offers the specialty expertise needed to provide the hospital surgical rescues required to optimally address these complications. [28] With the broad terrain of settings where acute surgical care is required, it is very clear that the Acute Care Surgery model will not be the complete answer to the nationwide workforce needs. Considering the medical landscape of this nation, with a well-documented decline in the general surgery workforce, a paradox is unveiled, given the fact that the general surgeon specialist remains the cornerstone of emergency surgical care across the country. This is problematic because of the more than 3,000 counties in the United States; there are nearly 1,200 counties without a general surgeon. There are an additional 358 counties with at least one surgeon but below the workforce threshold need. Thus, almost half (1,525) of all US counties have less than the lowest recommended standard for access to a general surgeon specialist. [29] There is no question that the establishment of both the Acute Care Surgery model and the Acute Care Surgery fellowship is needed to begin addressing the health care disparities in acute surgical care. An expected corollary to this aim in definitively addressing this health care disparity is the need for Acute Care Surgery to be an essential component of the core curriculum for general surgery training. The rationale for this is the fact that it will be the general surgeon who will likely fill that workforce void in the community setting. There will be a requisite skill set that the general surgeon specialist needs to provide optimal care for the surgical emergencies and critically ill patients who reside in those community settings not populated by Acute Care Surgeons. [30]

References 1. Committee to Develop the Reorganized Specialty of Trauma SCC, Emergency S. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58(3):614-6. 2. Kim PK, Dabrowski GP, Reilly PM, Auerbach S, Kauder DR, Schwab CW. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004;199(1):96-101. 3. Committee on Acute Care Surgery American Association for the Surgery of T. The acute care surgery curriculum. J Trauma. 2007;62(3):553-6. 4. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Acute care surgery: now that we have built it, will they come? J Trauma Acute Care Surg. 2013;74(2):463-8; discussion 8-9. 5. Dente CJ, Duane TM, Jurkovich GJ, Britt LD, Meredith JW, Fildes JJ. How much and what type: analysis of the first year of the acute care surgery operative case log. J Trauma Acute Care Surg. 2014;76(2):329-38; discussion 38-9. 6. Duane TM, Dente CJ, Fildes JJ, Davis KA, Jurkovich GJ, Meredith JW, et al. Defining the acute care surgery curriculum. J Trauma Acute Care Surg. 2015;78(2):259-63; discussion 63-4. 7. Davis KA, Dente CJ, Burlew CC, Jurkovich GJ, Reilly PM, Toschlog EA, et al. Refining the operative curriculum of the acute care surgery fellowship. J Trauma Acute Care Surg. 2015;78(1):192-6. 8. Burlew CC, Davis KA, Fildes JJ, Esposito TJ, Dente CJ, Jurkovich GJ. Acute Care Surgery Fellowship Graduates' Practice Patterns: The Additional Training Is an Asset. J Trauma Acute Care Surg. 2016. 9. Jurkovich G, Angood P, Britt L, Cioffi W, Cryer H, Esposito T, et al. Acute care surgery: trauma, crtical care and emergency surgery. A report from the Committee to Develop the Reorganzied Specialty of Trauma, Surgical Critcial Care, and Emergency Surgery. J Trauma. 2005;58:614-6. 10. Institute of Medicine NAoS. The future of emergency care: Key findings and recommendations fact sheet. Future of emergency care report 2006. 2007 [Available from: http://www.iom.edu/. . 11. The American Association for the Surgery of Trauma. [Available from: http://www.aast.org/Default.aspx. 12. Miller PR, Wildman EA, Chang MC, Meredith JW. Acute care surgery: impact on practice and economics of elective surgeons. J Am Coll Surg. 2012;214(4):531-5; discussion 6-8. 13. Santry HP, Pringle PL, Collins CE, Kiefe CI. 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". Surgery. 2014;155(5):809-25.

14. Davis KA, Jurkovich GJ. An update on Acure Care Surgery: Emergence of Acute Care Surgery. ACS Surgery News. 2015;June 11. 15. Helewa R, Kholdedbarin R, Hochman D. Attending surgeon burnout and satisfaction with the establishment of a regional acute care surgical service. J Can Surg. 2012;55(5):312-6. 16. Kalina M. Implementation of an Acute Care Surgery Service in a Community Hospital: Impact on Hospital Efficiency and Patient Outcomes. Am Surg. 2016;82(1):7984. 17. Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG. Characterizing the general surgery workforce in rural America. Arch Surg. 2005;140(1):74-9. 18. Lynge DC, Larson EH. Workforce issues in rural surgery. Surg Clin North Am. 2009;89(6):1285-91, vii. 19. Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart LG. A longitudinal analysis of the general surgery workforce in the United States, 1981-2005. Arch Surg. 2008;143(4):345-50; discussion 51. 20. AAMC. The Complexities of Physician Supply and Demand: Projections from 2014 to 2025 [Available from: https://www.aamc.org/download/458082/data/2016_complexities_of_supply_and_de mand_projections.pdf 21. Misercola B, Sihler K, Douglas M, Ranney S, Dreifus J. Transfer of acute care surgery patients in a rural state: a concerning trend. J Surg Res. 2016;206(1):168-74. 22. Narayan M, Tesoriero R, Bruns BR, Klyushnenkova EN, Chen H, Diaz JJ. Acute Care Surgery: Defining the Economic Burden of Emergency General Surgery. J Am Coll Surg. 2016;222(4):691-9. 23.

Seraphine J. Brentwood, Tennessee2016.

24.

OminiPoint. Durham, NC2016 [Available from: www.OmniPointsurgical.com.

25.

Rossi P. Data compiled from MediTech (TM). 2016.

26. Gale SC, Arumugam D, Dombrovskiy VY. Diverticulitis Outcomes are Equivalent Between Level 1 Trauma Centers and Community Hospitals in New Jersey. Am Surg. 2015;81(6):600-4. 27. Chana P, Burns EM, Arora S, Darzi AW, Faiz OD. A Systematic Review of the Impact of Dedicated Emergency Surgical Services on Patient Outcomes. Ann Surg. 2016;263(1):20-7. 28. Gamelli RL. Organization of faculty practice and resident training in acute care surgery in an academic medical center. Surgery. 2007;141(3):302-3. 29. Ward NS, Howell MD. Intensivist-to-patient ratios in ICUs: is there a number? Curr Opin Anaesthesiol. 2015;28(2):172-9. 30. Thanarajasingam U, McDonald FS, Halvorsen AJ, Naessens JM, Cabanela RL, Johnson MG, et al. Service census caps and unit-based admissions: resident workload,

conference attendance, duty hour compliance, and patient safety. Mayo Clin Proc. 2012;87(4):320-7. 31. Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-71. 32. Kalina M. Implementation of a Trauma Service Activation and Admission Policy for Very Elderly Trauma Patients: Impact on Hospital Efficiency and Patient Outcomes. Am Surg. 2016;82(6):493-6. 33. van der Wilden GM, Schmidt U, Chang Y, Bittner EA, Cobb JP, Velmahos GC, et al. Implementation of 24/7 intensivist presence in the SICU: effect on processes of care. J Trauma Acute Care Surg. 2013;74(2):563-7. 34. Kluger Y, Ben-Ishay O, Sartelli M, Ansaloni L, Abbas AE, Agresta F, et al. World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS). World J Emerg Surg. 2013;8(1):17. 35. Huddart S, Peden CJ, Swart M, McCormick B, Dickinson M, Mohammed MA, et al. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. Br J Surg. 2015;102(1):57-66. 36. Austin MT, Diaz JJ, Jr., Feurer ID, Miller RS, May AK, Guillamondegui OD, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005;58(5):906-10. 37. Scherer LA, Battistella FD. Trauma and emergency surgery: an evolutionary direction for trauma surgeons. J Trauma. 2004;56(1):7-12. 38. Kashuk JL, Klein Y, Bacchus H, Kluger YS. Acute care surgery: what's in a name? A new specialty comes of age. Isr Med Assoc J. 2013;15(4):147-51. 39. Reilly PM, Schwab CW. Acute care surgery: the academic hospital's perspective. Surgery. 2007;141(3):299-301. 40. Stanley MD, Davenport DL, Procter LD, Perry JE, Kearney PA, Bernard AC. An acute care surgery rotation contributes significant general surgical operative volume to residency training compared with other rotations. J Trauma. 2011;70(3):590-4. 41. Lim DW, Ozegovic D, Khadaroo RG, Widder S. Impact of an acute care surgery model with a dedicated daytime operating room on outcomes and timeliness of care in patients with biliary tract disease. World J Surg. 2013;37(10):2266-72. 42. Pillai S, Hsee L, Pun A, Mathur S, Civil I. Comparison of appendicectomy outcomes: acute surgical versus traditional pathway. ANZ J Surg. 2013;83(10):739-43. 43. Madore JC, Collins CE, Ayturk MD, Santry HP. The impact of acute care surgery on appendicitis outcomes: Results from a national sample of university-affiliated hospitals. J Trauma Acute Care Surg. 2015;79(2):282-8. 44. Cubas RF, Gomez NR, Rodriguez S, Wanis M, Sivanandam A, Garberoglio CA. Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: impact on timing and cost. J Am Coll Surg. 2012;215(5):715-21.

45. Lissauer ME, Galvagno SM, Jr., Rock P, Narayan M, Shah P, Spencer H, et al. Increased ICU resource needs for an academic emergency general surgery service*. Crit Care Med. 2014;42(4):910-7. 46. Ciesla DJ, Cha JY, Smith JS, 3rd, Llerena LE, Smith DJ. Implementation of an acute care surgery service at an academic trauma center. Am J Surg. 2011;202(6):779-85; discussion 85-6. 47. al-Ayoubi F, Eriksson H, Myrelid P, Wallon C, Andersson P. Distribution of emergency operations and trauma in a Swedish hospital: need for reorganisation of acute surgical care? Scand J Trauma Resusc Emerg Med. 2012;20:66. 48. Shafi S, Aboutanos MB, Agarwal S, Jr., Brown CV, Crandall M, Feliciano DV, et al. Emergency general surgery: definition and estimated burden of disease. J Trauma Acute Care Surg. 2013;74(4):1092-7. 49. Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, et al. Global disease burden of conditions requiring emergency surgery. Br J Surg. 2014;101(1):e9-22. 50. Bruns SD, Davis BR, Demirjian AN, Ganai S, House MG, Saidi RF, et al. The subspecialization of surgery: a paradigm shift. J Gastrointest Surg. 2014;18(8):1523-31. 51. Cohn SM, Price MA, Villarreal CL. Trauma and surgical critical care workforce in the United States: a severe surgeon shortage appears imminent. J Am Coll Surg. 2009;209(4):446-52 e4. 52. Hoyt DB, Kim HD, Barrios C. Acute care surgery: a new training and practice model in the United States. World J Surg. 2008;32(8):1630-5. 53. Britt RC, Weireter LJ, Britt LD. Initial implementation of an acute care surgery model: implications for timeliness of care. J Am Coll Surg. 2009;209(4):421-4. 54. Gutt CN, Encke J, Koninger J, Harnoss JC, Weigand K, Kipfmuller K, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg. 2013;258(3):385-93. 55. Kiviluoto T, Siren J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet. 1998;351(9099):321-5. 56. Lehane CW, Jootun RN, Bennett M, Wong S, Truskett P. Does an acute care surgical model improve the management and outcome of acute cholecystitis? ANZ J Surg. 2010;80(6):438-42. 57. Von Conrady D, Hamza S, Weber D, Kalani K, Epari K, Wallace M, et al. The acute surgical unit: improving emergency care. ANZ J Surg. 2010;80(12):933-6. 58. Britt RC, Bouchard C, Weireter LJ, Britt LD. Impact of acute care surgery on biliary disease. J Am Coll Surg. 2010;210(5):595-9, 9-601. 59. Norman DC, Yoshikawa TT. Intraabdominal infection: diagnosis and treatment in the elderly patient. Gerontology. 1984;30(5):327-38.

60. Smithy WB, Wexner SD, Dailey TH. The diagnosis and treatment of acute appendicitis in the aged. Dis Colon Rectum. 1986;29(3):170-3. 61. Horattas MC, Guyton DP, Wu D. A reappraisal of appendicitis in the elderly. Am J Surg. 1990;160(3):291-3. 62. Livingston EH, Fomby TB, Woodward WA, Haley RW. Epidemiological similarities between appendicitis and diverticulitis suggesting a common underlying pathogenesis. Arch Surg. 2011;146(3):308-14. 63. Earley AS, Pryor JP, Kim PK, Hedrick JH, Kurichi JE, Minogue AC, et al. An acute care surgery model improves outcomes in patients with appendicitis. Ann Surg. 2006;244(4):498-504. 64. Ball CG, Hameed SM, Brenneman FD. Acute care surgery: a new strategy for the general surgery patients left behind. Can J Surg. 2010;53(2):84-5. 65. Tincknell L, Burton S, Cooke C, Black S, Andreani S, Jourdan I, et al. The emergency surgical team - the way forward in emergency care? Ann R Coll Surg Engl. 2009;91(1):18-22. 66. Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012;143(5):1179-87 e1-3. 67. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978;12:85-109. 68. ES H, AM C, AB C. The surgical management of acute diverticulitis. Med J Aust. 1963;50(1):780–2. 69. Moore FA, Moore EE, Burlew CC, Coimbra R, McIntyre RC, Jr., Davis JW, et al. Western Trauma Association critical decisions in trauma: management of complicated diverticulitis. J Trauma Acute Care Surg. 2012;73(6):1365-71. 70. Davis KA, Rozycki GS. Acute care surgery in evolution. Crit Care Med. 2010;38(9 Suppl):S405-10. 71. Dinan KA, Davis JW, Wolfe MM, Sue LP, Cagle KM. An acute care surgery fellowship benefits a general surgical residency. J Trauma Acute Care Surg. 2014;77(2):209-12. 72. Frankel HL, Butler KL, Cuschieri J, Friese RS, Huynh T, Mohr AM, et al. The role and value of surgical critical care, an essential component of Acute Care Surgery, in the Affordable Care Act: a report from the Critical Care Committee and Board of Managers of the American Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2012;73(1):20-6. 73. American Board of Surgery. ABS statement regarding residency redesign. 2016 [Available from: http://www.absurgery.org/default.jsp?news_resredesign0416. 74. Becher R, Hoth J, PR M, NT M, MC C, JW M. A Critical Assessment of Outcomes in Emergency versus Nonemergency General Surgery Using the American College of

Surgeons National Surgical Quality Improvement Program Database. Am Surg. 2011;77:9561-9. 75. Ingraham AM, Cohen ME, Raval MV, Ko CY, Nathens AB. Variation in quality of care after emergency general surgery procedures in the elderly. J Am Coll Surg. 2011;212(6):1039-48. 76. Tominaga GT, Staudenmayer KL, Shafi S, Schuster KM, Savage SA, Ross S, et al. The American Association for the Surgery of Trauma grading scale for 16 emergency general surgery conditions: Disease-specific criteria characterizing anatomic severity grading. J Trauma Acute Care Surg. 2016;81(3):593-602. 77. Bulger EM, Maier RV, Sperry J, Joshi M, Henry S, Moore FA, et al. A Novel Drug for Treatment of Necrotizing Soft-Tissue Infections: A Randomized Clinical Trial. JAMA Surg. 2014;149(6):528-36. 78. Moore L, Lavoie A, Le Sage N, Bergeron E, Emond M, Abdous B. Consensus or data-derived anatomic injury severity scoring? J Trauma. 2008;64(2):420-6. 79. Finlayson E, Birkmeyer J. Benchmarking Surgical Outcomes ACS Surgery: Principles and Practice. 6th: BC Decker; 2007. p. 9-13. 80. Lee CN, Ko CY. Beyond outcomes--the appropriateness of surgical care. JAMA. 2009;302(14):1580-1.

Gregory J Jurkovich, MD Gregory “Jerry” Jurkovich, MD, is the Donant Professor of Trauma Surgery and ViceChairman for Clinical Affairs and Quality of the Department of Surgery at the UC Davis Health System in Sacramento, California.. Prior to relocating to California, Dr. Jurkovich served as Director of Surgery and Trauma Services at Denver Health, and the Rockwell Professor of Surgery at the University of Colorado. This appointment followed nearly 24 years at the University of Washington and Harborview Medical Center in Seattle as Professor and Chief of Trauma. He began his surgical career as Chief of Trauma at the University of South Alabama. Dr. Jurkovich is well known for his leadership of the AAST Committee on the Acute Care Surgeon, working to define the future training and practice paradigm for trauma surgery that combines surgical critical care, emergency general surgery, and trauma surgery.

Kimberly A. Davis, MD, MBA Kimberly A. Davis is a Professor of Surgery and the Surgical Vice Chairman for Clinical Affairs at the Yale School of Medicine. She is the Chief of the General Surgery, Trauma and Surgical Critical Care. After a BS in Molecular Biophysics and Biochemistry at Yale, she attended Albany Medical College, did a surgical residency at the Brown University/Rhode Island Hospital program, and a fellowship in trauma and surgical critical care at the University of Tennessee - Memphis. Dr. Davis received her MBA from the Yale School of Management in 2012.

Clay Cothren Burlew, MD Dr. Clay Cothren Burlew is a Professor of Surgery at the University of Colorado/Denver Health Medical Center. She attended medical school at UT Southwestern, and was elected to the Alpha Omega Alpha medical honor society. She completed her general surgery residency and surgical critical care fellowship at the University of Colorado. She is the Director of the Surgical Intensive Care Unit at Denver Health, and is also the Program Director of the Surgical Critical Care and Trauma & Acute Care Surgery Fellowships. Her research interests include hemorrhage control for pelvic fractures, blunt cerebrovascular injuries, and management of the open abdomen.

Christopher Dente, MD: Christopher Dente, MD, is a Professor of Surgery for Emory University at Grady Memorial Hospital. He received his medical degree from the Medical College of Pennsylvania and subsequently completed a general surgery residency at Wayne State University/Detroit Medical Center. He went on to complete a two-year trauma/surgical critical care fellowship at Emory University. He maintains a clinical focus in trauma and Acute Care Surgery and has broad based research interest in a variety of Acute Care Surgery topics, most recently in the creation of Bayesian Belief Network driven clinical decision support tools for critically ill and injured patients.

Joeseph M. Galante MD Joseph M. Galante is an Associate Professor of Surgery and Chief of Trauma and Acute Care, as well as Vice Chair for Education in the University of California, Davis Department of Surgery. He attended Temple University for medical school. His general surgery residency and surgical critical care fellowship were completed at UC Davis. He has served as a forward deployed combat surgeon in Afghanistan in 2010. His research focuses on cardiovascular trauma and the combined inflammatory and coagulation response to injury.

Joel Goodwin, MD Joel Goodwin, MD, is an Attending Surgeon and Medical Director of OmniPoint Surgery, a subsidiary of LifePoint Health ™. He is a graduate of UNC Chapel Hill School of Medicine, completed his General Surgery Residency at Virginia Mason Medical Center, and did a Surgical Critical Care Fellowship at East Carolina University. He founded OmniPoint in 2013 with the goal of providing uncompromising quality surgical services and consultation to the community hospitals in the LifePoint system, which now includes 72 facilities.

Bellal Joseph, MD Dr. Bellal Joseph is Associate Professor and Vice Chairman of Research and Knowledge Expansion in the Department of Surgery at the University of Arizona College of Medicine. He received his surgical training at Henry Ford Hospital in Detroit, Michigan and subsequently did his fellowship at Shock Trauma Center in Baltimore. Dr. Joseph joined University of Arizona in 2009 and since excelled as a national figure in trauma surgery. In addition to being a board certified clinician, he is also Associate Director of Surgical Critical Care/ Acute Care fellowship and the Director of the Teletrauma Program, He has extensively invested himself in research with over 140 peer reviewed publications. BIOSKETCH Dr. Viraj Pandit, MD, is a General Surgery Resident (PGY III) at the University of Arizona. He graduated in 2012 from Dr. Vaishampayan Memorial Government Medical College, India and then joined the International Research Fellowship Program at the University of Arizona, Division of Trauma in March 2012. He conducted research under the mentorship of Dr. Bellal Joseph and Dr. Peter Rhee and excelled in clinical and basic science research working on several projects including; geriatric trauma, traumatic brain injury, rehabilitation after traumatic injury, coagulopathy of trauma, medical

technology and telemedicine, and injury prevention. He is actively involved in research with over 90 peer reviewed publications and aims to be an academic surgeon in future.

Marc de Moya, MD After attending medical school at Temple University, he completed his General Surgical residency at St. Barnabas/Jersey City Medical Center in New Jersey. He went on to complete his trauma/critical care fellowship at the Ryder Trauma Center/Jackson Memorial Hospital in Miami. He is an Associate Professor and is the Trauma/Acute Care Surgery fellowship Program Director, Medical Director of the SICU, Clerkship Director for the Harvard Medical School Surgical clerkship, and Associate Program Director for the General Surgical Residency. He has published over 100 peer-reviewed articles and several chapters and has received numerous grants from the department of defense for trauma and simulation research.

Robert Becher, MD Robert D. Becher, MD, MS, is an Assistant Professor of Surgery at the Yale School of Medicine. He received his medical degree at the Brown University School of Medicine, and completed a residency in general surgery at Wake Forest University Medical Center. During his research fellowship at Wake Forest, he earned an MS degree in clinical and population translational sciences. Dr. Becher completed his acute care surgery fellowship at the University of Pittsburgh Medical Center. His research focus is on the systems of emergent surgical care.