Invited commentary

Abstract

Dr Harris and colleagues argue that services for vascular acute care surgery (VACS) should be established in tertiary referral centers for nonelective care. Further, they speculate that additional training and advanced certification of vascular surgeons and VACS program accreditation may be required in the future. Their analyses likely overestimate the burden of emergency vascular care. The Health Services Cost Review Commission inpatient data set they reviewed provided minimal information about the nature of patients' vascular conditions and procedures. As expected, urgent or emergency hospitalization was associated with greater resource utilization and poorer outcomes. The analysis, however, could not determine whether vascular disease or injury was the reason for admission or whether vascular procedures were needed during hospitalization to address complications or comorbidities. Vascular diagnoses were not specified, nor was the urgency of procedures performed. Many nonelective hospital admissions for vascular diagnoses are not true emergencies. Emergency Department cases may become “acute” because of lack of insurance, inadequate primary care, or because of a primary care provider's choice to first send the patient to the Emergency Department for management. All board-certified vascular surgeons, regardless of their training pathway, should be competent to handle most nonelective problems, including thromboembolectomy, vascular access procedures, angiography, inferior vena cava filter placements, amputations, treatment of pseudoaneurysms, and the like. These procedures should not require transfer to an acute vascular care center. Complex care is already regionalized to larger centers. There are 5564 United States hospitals,1American Hospital Association AHA Hospital Statistics. Fast facts on US hospitals.http://www.aha.org/research/rc/stat-studies/fast-facts.shtmlGoogle Scholar but only 3767 vascular surgeons.2American Board of Surgery Statistics and pass rates.http://www.absurgery.org/default.jsp?statsummaryGoogle Scholar The need for triage and transfer should be considered the norm. Although there can be problems with access to care and timeliness of transfer, it is unlikely that establishing VACS teams at regional centers will be the answer. Interestingly, our group at a medium-sized academic medical center (a level 1 trauma center) instituted an acute vascular surgery care service. We found the change unhelpful. After a 1-year trial, we reverted to our traditional coverage model. We still handle ruptured aneurysms, acute limb ischemia, and other complex vascular problems, but without a service dedicated to acute problems. Implementation a VACS service may make sense where most of the work is urgent or an emergency. That does not mean it is right for most programs. Management of clinical services needs to be based on referral patterns, local resources, and institutional priorities, not national directives. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Defining the burden, scope, and future of vascular acute care surgeryJournal of Vascular SurgeryVol. 66Issue 5PreviewThe paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surgical procedures in Maryland. Full-Text PDF Open Archive