Acute Care Surgery Service Research Articles

Monitoring Perioperative Services Using 3D Multi-Objective Performance Frontiers

The Acute Care Surgery model has been widely adopted by hospitals across the United States, with Acute Care Surgery services managing Emergency General Surgery patients that were previously being treated by General Surgery. In this analysis, we evaluate the impact of an Acute Care Surgery service model on General Surgery at the University of Vermont Medical Center using three metrics: under-utilized time, spillover time, and a financial ratio of work Relative Value Units over clinical Full Time Equivalents. These metrics are evaluated and used to identify three-dimensional Pareto optimality of General Surgery prior to and after the October 2015 tactical allocation to the Acute Care Surgery model. Our analysis was further substantiated using a Markov Chain Monte Carlo model for Bayesian Inference. We applied multi-objective Pareto and Bayesian breakpoint analysis to three operating room metrics to assess the impact of new operating room management decisions. In the two-dimensional space of Fig.2, panel a), the post-tactical allocation front lies closer to the origin representing more optimal solutions for productivity and under-utilized time. The post-tactical allocation front is also closer to the origin for productivity and spillover time as shown in the two-dimensional space of Fig.2, panel b). The results of the three-dimensional multi-objective analysis of Fig.3 illustrate that the GS post-tactical allocation Pareto-surface is contained within a much smaller volume of space than the GS pre-tactical allocation Pareto-surface. The post-tactical allocation Pareto-surface is slightly lower along the z-axis, representing lower productivity than the pre-tactical allocation surface. This methodology might contribute to the external benchmarking and monitoring of perioperative services by visualizing the operational implications following tactical decisions in operating room management.

A special acute care surgery model for dealing with dilemmas involved in emergency department in China

There was a fast growth in the number and the formation of emergency department (ED) visits in China during the twenty-first century. As a result, engaging special medical model will be essential to decompressing the ED visits. To do this, it will be important to understand which specific aspects to focus interventions on for the greatest impact. To characterize the emergency surgery patients who were seen and discharged from ED. Retrospective cohort study of hospitalized emergency surgery patients currently under the care from specialists presenting to an urban, university affiliated hospital between 01 January 2018 and 1 January 2019. This study will highlight some of the controversies and challenges and key lessons learned. During the study period there were 231,229 ED visits; 4100 of these patients were admitted for Acute care surgery (ACS) service. Multivariate analysis identified age ≧ 65 (p = 0.023; odds ratio, OR = 2.66), ACS model (p = 0.000, OR = 0.18), ICU stay (p = 0.000, OR = 118.73) as factors associated with in-hospital mortality. There was a increase in length of stay between young and elderly postoperative patients when stratifying patients by age (11.67 ± 9.48 vs 13.95 ± 9.11 p < 0.05). ED overcrowding is not just an ED problem. ED overcrowding is a systems problem requiring a systematic facility-wide multidisciplinary response. Continuous and high-quality surveillance data across China are needed to estimate the acute care surgery model which used to deal with ED overcrowding.

Does Wound Management Technique Impact Surgical Site Infection in Open Emergency Colon Procedures?

Emergency open large bowel procedures have higher rates of intraoperative contamination and increased risk of surgical site infection (SSI) than elective colon surgeries. Several wound management strategies have been proposed, such as vacuum-assisted closure (VAC) therapy and delayed primary closure to improve results. The purpose of this study is to evaluate the relationship between wound management technique and SSI and other quality measures. We performed a retrospective review of patients undergoing open emergency colon surgery from January 2017 to December 2018 by our acute care surgery service. The primary outcome measure was incidence of SSI. Secondary outcome measures included length of stay, reoperation, and 30-day readmission. A total of 118 patients were included in the study, with a mean age of 62.8years and mean BMI of 28.8. Overall incidence of SSI was 19.5%. There was no significant difference in incidence of SSI, reoperation, or 30-day readmission when stratifying by wound management technique or procedure type after controlling for confounding variables. Notably, patients managed with VAC therapy had a statistically significant longer average length of stay and higher total postoperative antibiotic days (both P = .001) than other techniques. We conclude from our data that wound management technique does not seem to influence rate of SSI, but wound management may influence length of stay or antibiotic duration. These findings suggest that there may not be an advantage to alternative methods of wound management in this high-risk population. Further prospective evaluation should be performed to confirm these findings.

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis

BackgroundEfficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed “FASTPASS” (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. MethodsFASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. ResultsDuring our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. ConclusionsIn this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

Euglycemic Diabetic Ketoacidosis in the Surgical Patient.

Postoperative euglycemic diabetic ketoacidosis (EDKA), a rare cause of acidosis, results from the metabolic derangement of diabetes and is not associated with a surgical complication requiring reoperation. Our acute care surgery service has managed several recent patients who developed postoperative EDKA. Our group was befuddled by the initial case but subsequently quickly recognized and managed the condition. The purpose of this report is to discuss the pathophysiology of EDKA, summarize 3 recent cases, and increase awareness about the condition to permit prompt recognition and treatment.

Fast track pathway provides safe, value based care on busy acute care surgery service.

Fast track (FT) pathways have been adopted across a multitude of elective surgeries but have been slow to be adopted into the acute care surgery realm. We hypothesized that an FT pathway for acute cholecystitis patients would decrease patient length of stay and resource utilization. All patients at two hospitals, one with an FT pathway and one with a traditional pathway, who underwent an urgent laparoscopic cholecystectomy for acute cholecystitis between May 1, 2019, and October 31, 2019, were queried using CPT codes. Exclusion criteria were conversion to open or partial cholecystectomy. Retrospective chart review was used to gather demographics, operative, hospital course, and outcomes. Time to operating room, hospital length of stay, and resource utilization were the primary outcomes. There was a total of 479 urgent laparoscopic cholecystectomies performed, 430 (89.8%) were performed under the FT pathway. The median (interquartile range [IQR]) time to the operating room was not different: 14.1 hours (IQR, 8.3-29.0 hours) for FT and 18.5 hours (IQR, 11.9-25.9 hours) for traditional (p = 0.316). However, the median length of stay was shorter by 15.9 hours in the FT cohort (22.6 hours; IQR, 14.2-40.4 hours vs. 38.5 hours; IQR, 28.3-56.3 hours; p < 0.001). Under the FT pathway, 33.0% of patients were admitted to the hospital and 75.6% were discharged from the postanesthesia care unit, compared with 91.8% and 12.2% on the traditional pathway (both p < 0.001). There were 59.6% of the FT patients that received a phone call follow up, as opposed to 100% of the traditional patients having clinic follow up (p < 0.001). The emergency department bounce back rate, readmission rates, and complication rates were similar (p > 0.2 for all). On multivariate analysis, having a FT pathway was an independent predictor of discharge within 24 hours of surgical consultation (odds ratio, 7.65; 95% confidence interval< 2.90-20.15; p < 0.001). Use of a FT program for patients with acute cholecystitis has a significant positive impact on resource utilization without compromise of clinical outcomes. Therapeutic/care management, level IV.

Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines

The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines. This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs). Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01). Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.

Impact of the COVID-19 pandemic on the outcome, morbidity, and mortality of acute care surgery patients: A retrospective cohort study

BackgroundCoronavirus disease (COVID-19) has impacted both emergency and elective surgical management owing to its highly infectious nature and the shortage of personal protective equipment. This study aimed to review the outcomes of emergency surgical conditions and trauma during the pandemic lockdown. Material and methodsWe retrospectively reviewed and collected data from patients who attended the Acute Care Surgery Service from 1st April to May 31st, 2020 during Thailand's COVID-19 pandemic lockdown. We separated staff and performed preoperative COVID-19 swab testing on all patients to assess the requirement for personal protective equipment. Compared with previous years of service, of 2018 and 2019. Preoperative COVID-19 testing was performed using multiplex and manual RT-PCR. Morbidity and mortality, consultation time, and waiting time to surgery were analyzed. ResultsA total of 61 patients were enrolled. The average age of patients was 53.8 years. The average consultation time, waiting time to surgery, and surgical duration were 10 min, 660 min, and 88.77 min, respectively. The average time taken to obtain the preoperative COVID-19 test result was 227.26 min. The morbidity and mortality rates were 9.84% and 1.64%, respectively. Compared with the same period in 2018 and 2019, consultation time was significantly faster (10 min; p = 0.033) and waiting time to surgery was significantly longer (660 min, respectively; p = 0.011). Morbidity and mortality between pandemic period and the previous year of service were not significantly different. No medical workers were infected with COVID-19. ConclusionsDuring the COVID-19 pandemic, optimal triage of emergency patients is key. Waiting for preoperative COVID-19 swab testing in emergency case is safe and results in good outcomes. Although the waiting time to surgery was significantly longer owing to the time required to receive preoperative COVID-19 swab results, morbidity and mortality rates were unaffected.

Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic.

BackgroundThe role of an acute care surgery (ACS) service during the COVID-19 pandemic is not well established.MethodsA retrospective review of the ACS service performance in an urban tertiary academic medical center. The study was performed between January and May 2020. The demographics, clinical characteristics, and outcomes of patients treated by the ACS service 2 months prior to the COVID surge (pre-COVID group) and during the first 2 months of the COVID-19 pandemic (surge group) were compared.ResultsTrauma and emergency general surgery volumes decreased during the surge by 38% and 57%, respectively; but there was a 64% increase in critically ill patients. The proportion of patients in the Department of Surgery treated by the ACS service increased from 40% pre-COVID to 67% during the surge. The ACS service performed 32% and 57% of all surgical cases in the Department of Surgery during the pre-COVID and surge periods, respectively. The ACS service managed 23% of all critically ill patients in the institution during the surge. Critically ill patients with and without confirmed COVID-19 infection treated by ACS and non-ACS intensive care units during the surge did not differ in demographics, indicators of clinical severity, or hospital mortality:13.4% vs. 13.5% (P = .99) for all critically ill patients; and 13.9% vs. 27.4% (P = .12) for COVID-19 critically ill patients.ConclusionAcute care surgery is an “essential” service during the COVID-19 pandemic, capable of managing critically ill nonsurgical patients while maintaining the provision of trauma and emergent surgical services.Level of EvidenceIII.Study TypeTherapeutic.

Morbidity, mortality, and risk factors of emergency colorectal surgery among older patients in the Acute Care Surgery service: A retrospective study

BackgroundAcute Care Surgery (ACS) is a rapid response system in emergency surgical conditions. The patients who over 60 year-old have numerous factors associated with high mortality and morbidity in emergency colorectal surgery. We aimed to identify potentially preventable risk factors, to improve patients’ outcomes. MethodsA retrospective review of patients age over 60 year-old undergoing emergency colorectal surgery in the ACS service from August 1, 2017 through November 30, 2019. ResultsNinety-two patients were analyzed, average age 72.41 years. The most common diagnosis was complicated colorectal cancer (76, 83.52%) with locations on the right (37, 41.51%), left (35,39.33%), and rectum (17, 19.10%). Clinical presentations were obstruction without perforation (61, 67.03%), perforation (25, 27.17%), and ischemia (2, 2.17%). Overall mortality was 6.52%. Cause of death included septic shock (3, 50%); respiratory failure (3, 50%); and pulmonary embolism (1, 16.67%). Morbidity from surgical and medical complications were 41.30% and 26.08%, respectively. For all causes, operations included resection with primary anastomosis (62, 71.26%); Hartmann's operation (11, 12.64%); and loop colostomy (12, 13.79%). Average operative time was 159.86 min. In emergency colorectal surgery, pre-existing heart disease, clinical perforation, and ventilator dependency increased risk of death 7.6-, 16.5-, and 0.08-fold, respectively. ConclusionClinical perforation leads to sepsis and septic shock in older patients, this may be modifiable to improve mortality by developing an early, rapid, protocol-driven surgical sepsis fast-track process. Ventilator dependency is potentially modifiable with postoperative advanced surgical critical care. The non-modifiable risk factor of co-morbid heart disease might be improved by postoperative advanced critical care for close monitoring.

Retroperitoneal perforation of the descending colon diverticulitis presenting with systemic emphysema.

A 75-year-old man was admitted to the cardiac care unit because of congestive heart failure (CHF) secondary to non-ST elevated myocardial infarction (NSTEMI). His medical history included CHF, hypertension, diabetes, bronchial asthma, and hyperuricemia. He denied any past surgical interventions. At admission, the patient was intubated and underwent percutaneous coronary angioplasty (PCA). His hospital course was complicated with refractory respiratory failure due to pulmonary edema, pneumonia, and bronchial asthma. He was intubated three times in 18 days. Steroids used to treat his asthma included intravenous methylprednisolone 40 mg for 3 days, which was switched to oral prednisone 30 mg, tapering to 5 mg over 12 days. Ceftriaxone was administered on hospital days 4–11 to treat pneumonia. He was finally extubated on hospital day 18, at which time routine chest radiography showed pneumomediastinum, subcutaneous emphysema, and subdiaphragmatic free air (figure 1). He was afebrile and his vital signs were normal except for mild tachycardia (heart rate 105 bpm). He presented with abdominal bloating but denied abdominal pain. He exhibited crepitation all over his body. His abdomen was distended and soft. His white cell count was 1.21x10∧9/L, blood urea nitrogen 89.6 mg/dL, and creatinine 4.35 mg/dL. Non-contrast CT showed extensive subcutaneous emphysema over the chest and abdominal wall, pneumomediastinum without pneumothorax, massive pneumoperitoneum, and pneumoretroperitoneum. Diffuse mesenteric emphysema was observed without ascites (figure 2). The acute care surgery service was consulted. Figure 1 Chest radiograph shows pneumomediastinum (thin arrows), subcutaneous emphysema …

Impact of interhospital transfer on patient outcomes in emergency general surgery

BackgroundEmergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers. MethodsWe performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority. ResultsA total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3–2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2–3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6–1.9]; P = .79) on regression analysis. ConclusionComplex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers.

Using telemedicine on an acute care surgery service: improving clinic efficiency and access to care.

Telemedicine has been shown to improve patient access to medical care while potentially improving overall healthcare efficiency. It has not been consistently explored on an acute care surgery service as a method of increasing clinic availability and efficiency within a safety-net hospital system. Socioeconomic hardships associated with an in-person clinic visit can deter patients with limited resources. A virtual clinic for post-operative laparoscopic cholecystectomy patients was developed. We hypothesized that a virtual follow-up increases clinic efficiency and availability for new patients without compromising patient safety. A retrospective review of patient and clinic outcomes before and after implementing virtual post-op visits for uncomplicated laparoscopic cholecystectomy patients on an acute care surgery service was performed. Providers called post-operative patients using a standardized questionnaire. Data included outpatient clinic composition (new vs. post-operative patients), elective operations scheduled, emergency department visits, and loss to follow-up rates. February to March 2017 was the baseline pre-intervention period, while February to March 2019 was post-intervention. Pre-intervention clinics consisted of 17% new and 50% post-op visits, in comparison to 31% new and 27% post-op visits in the post-intervention group (p < 0.01). Elective operations scheduled increased slightly from 8.4 to 11.5 per 100 patient visits, but was not statistically significant (p = 0.09). There was no change in the number of post-operative patients returning to the emergency department (p = 0.91) or loss to follow-up (p = 0.30) rates. Through the implementation of virtual post-operative visits for laparoscopic cholecystectomy patients, clinic efficiency improved by increasing new patient encounters, decreasing post-operative volume, and trending towards increased operations scheduled. This change did not compromise patient safety. Further implementation of telemedicine on an acute care surgery service is a promising method to expand services offered to an at-risk population and increase efficiency in a resource-limited environment.

Thigh Ultrasound Used to Identify Frail Elderly Patients with Sarcopenia Undergoing Surgery: A Pilot Study

BackgroundComputed tomography (CT) scan quantifying skeletal muscle mass is the gold standard tool to identify sarcopenia. Unfortunately, high cost, limited availability, and radiation exposure limit its use. We suggest that ultrasound of the thigh muscle could be an objective, reproducible, portable, and risk-free tool, used as a surrogate to a CT scan, to help identify frail patients with sarcopenia. Materials and methodsWe included 49 patients over 64 y old, referred to the acute care surgery service. An ultrasound of thigh muscle thickness was standardized to patient thigh length (U/Swhole/L). CT skeletal muscle index (SMI) was calculated using skeletal muscle surface area of the L3 region divided by height2. Frailty status was assessed using the Canadian Study of Healthy Aging Clinical Frailty Scale. ResultsThe mean (SD) age was 76 (8) y, and 34% (n = 17) were men. CT-defined sarcopenia was identified in 65% (n = 11) of men and 75% (n = 24) of women. In general, women had longer stay in hospital than men (mean + SD 14 ± 9 versus 7 ± 3 d, P = 0.003). There was a significant positive correlation between thigh U/Swhole/L and CT SMI. There was an inverse correlation between thigh U/Swhole/L and frailty score; a similar relationship was observed between CT SMI and frailty. There was an association between U/Swhole/L and postoperative major complications. ConclusionsThis prospective observational study illustrates that the U/Swhole/L index can be used as a surrogate to CT scan, whereby it can identify elderly frail patients with sarcopenia. Thigh ultrasound should be further tested as an objective tool to assess for stratifying frailty.

Indocyanine green does not decrease the need for bail-out operation in an acute care surgery population

BackgroundThe use of indocyanine green during laparoscopic cholecystectomy has been postulated to help to define anatomy. Studies have not specifically evaluated patients with acute cholecystitis. We sought to assess whether use of indocyanine green can decrease the rate of bail-out operation (subtotal cholecystectomy or conversion to an open operation) in an acute care surgery population where acute cholecystitis is more frequent. MethodsUsing a retrospective cohort design, we examined all inpatient cholecystectomies performed by the acute care surgery service under urgent or semiurgent (biliary colic as the presentation in the emergency room) conditions at a single institution from 7/1/18 to 6/30/19 during which indocyanine green was available for use at the surgeon’s discretion. ResultsA total of 198 patients were included in the analysis. Demographic variables were similar in groups receiving indocyanine green versus not. Pathology confirmed acute cholecystitis was present in 96 of 198 (48.5%) patients; of those, 55 (57.2%) received indocyanine green. Indocyanine green did not change the rate of bail-out operation between patients who received indocyanine green and those who did not (6.7% vs 4.3%, P = .468). No significant differences in complications were observed. Bail-out operation was more likely in cases of acute cholecystitis (9.4%) versus nonacute cholecystitis (2.0%) (odds ratio = 5.172, P = .039). In patients with acute cholecystitis, indocyanine green did not change the rate of bail-out operation (indocyanine green: 12.7% vs no indocyanine green: 4.9%, P = .293). ConclusionThis is the first series looking at the use of indocyanine green specifically in an acute care surgery population. Indocyanine green did not decrease operative time or need for a bail-out operation in acute cholecystitis. Further study is needed to determine whether indocyanine green use is justified in this population.

Impact of geriatric trauma service on the outcome of older trauma patents.

The number of geriatric trauma patients is rising; yet, there is no established best team to care for them. This study analyzed a geriatric trauma service (GTS) that is integrated into the trauma surgery workflow rather than a separate consultation service. We hypothesize this team will lead to decreased mortality, shorter length of stay and increased favorable discharges for geriatric trauma patients. In July 2017, we established a GTS consisting of geriatric nurse practitioners who were part of the hospital's geriatrics service, trauma surgeons and surgery residents on the acute care surgery service. The geriatric nurse practitioners were integrated into the trauma surgery workflow and functioned as independent members. The GTS responded to traumas and consultations for patients aged ≥65 years. Trauma surgeons carried out intensive care and operative management, while the geriatric nurse practitioners managed medical issues, family communication and end-of-life planning. We carried out a 2 year retrospective analysis of trauma patients aged ≥65 years seen at Dell Seton Medical Center at the University of Texas, Austin, Texas, USA, comparing patient outcomes before and after the GTS. The primary outcome was mortality, whereas secondary outcomes included hospital days, intensive care unit days, and discharge disposition. We found no difference in mortality, intensive care unit days or hospital days with the GTS. However, post-GTS patients were more often discharged to home, rehabilitation, or hospice, and less often to nursing homes. An integrated geriatric and trauma team is feasible, and significant changes in disposition can be made by utilizing geriatric nurse practitioners. Geriatr Gerontol Int 2020; 20: 817-821.

The association between self-declared acute care surgery services and critical care resources: Results from a national survey

We examined differences in critical care structures and processes between hospitals with Acute Care Surgery (ACS) versus general surgeon on call (GSOC) models for emergency general surgery (EGS) care. 2811 EGS-capable hospitals were surveyed to examine structures and processes including critical care domains and ACS implementation. Differences between ACS and GSOC hospitals were compared using appropriate tests of association and logistic regression models. 272/1497 hospitals eligible for analysis (18.2%) reported they use an ACS model. EGS patients at ACS hospitals were more likely to be admitted to a combined trauma/surgical ICU or a dedicated surgical ICU. GSOC hospitals had lower adjusted odds of having 24-h ICU coverage, in-house intensivists or respiratory therapists, and 4/6 critical-care protocols. Critical care delivery is a key component of EGS care. While harnessing of critical care structures and processes varies across hospitals that have implemented ACS, overall ACS models of care appear to have more robust critical care practices.

Acute care surgery, trauma and disaster relief: a clinical exchange between the University of British Columbia and the Mexican Red Cross.

Our objective was to establish a sustainable educational partnership and clinical exchange between the trauma services at Vancouver General Hospital (VGH) and the Mexican Red Cross hospital in Mexico City (Hospital Central de la Cruz Roja [HCCR] Polanco). In 2017, a general surgery resident in postgraduate year 4 travelled from VGH to HCCR Polanco for the initial exchange, followed by a trauma fellow. The surgical case volumes in a month at VGH and a month at HCCR Polanco were compared. At the end of the exchange, a 36-item Likert style questionnaire was administered to the Mexican surgeons and residents who interacted with the Canadian resident and fellow during the exchange. The most commonly performed procedures on the VGH acute care surgery service were laparoscopic cholecystectomy (35%) and laparoscopic appendectomy (17%). The most commonly performed procedures on the VGH trauma service were chest tube insertions (24%) and tracheostomies (24%). The most commonly performed procedures at HCCR Polanco were surgery for penetrating abdominal trauma (19%) and extremity trauma (13%). The survey results indicated that the costs of travel and accommodation were obstacles to future exchanges. All survey respondents wanted to continue collaborating with Canadians on clinical and research endeavours, felt that hosting Canadian residents was a valuable experience and felt that visiting VGH would also be valuable. Canadian surgical trainees gained valuable exposure to operative trauma during the exchange. The mix of operations performed at VGH and HCCR Polanco was vastly different; therefore, the exchange broadened the trainees' surgical experience. There was a unanimously positive response to the exchange among the Mexican survey respondents. This exchange is part of a long-term collaboration between our surgical centres.

Development of an enhanced acute care surgery service in response to the COVID-19 global pandemic

BackgroundAs the COVID-19 pandemic sweeps across the world, healthcare departments must adapt to meet the challenges of service provision and staff/patient protection. Unlike elective surgery, acute care surgery (ACS) workloads cannot be artificially reduced providing a unique challenge for administrators to balance healthcare resources between the COVID-19 surge and regular patient admissions. MethodsAn enhanced ACS (eACS) model of care is described with the aim of limiting COVID-19 healthcare worker and patient cross-infection as well as providing 24/7 management of emergency general surgical (GS) and trauma patients. The eACS service comprised 5 independent teams covering a rolling 1:5 24-hr call. Attempts to completely separate eACS teams and patients from the elective side were made. The service was compared to the existing ACS service in terms of clinical and efficiency outcomes. Finally, a survey of staff attitudes towards these changes, concerns regarding COVID-19 and psychological well-being was assessed. ResultsThere were no staff/patient COVID-19 cross-infections. Compared to the ACS service, eACS patients had reduced overall length of stay (2-days), time spent in the Emergency Room (46 min) and time from surgery to discharge (2.4-hours). The eACS model of care saved financial resources and bed-days for the organisation. The changes were well received by team-members who also felt that their safety was prioritised. ConclusionIn healthcare systems not overwhelmed by COVID-19, an eACS model may assist in preserving psychological well-being for healthcare staff whilst providing 24/7 care for emergency GS and trauma patients.

Nimble, Together: A Training Program's Response to the COVID-19 Pandemic.

Nimble, Together: A Training Program's Response to the COVID-19 Pandemic.