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In this, my last blog in a series about the Acute Care Surgery model, let’s review the benefits for general surgeons.

For surgeons who may not want to start a private practice or who may be looking for alternatives to that career path, an acute care surgery service represents a viable choice. It’s certainly challenging and gratifying on a professional level, and as we collaborate as a team, our skills and efficiency just get better and better. We see improved outcomes in our patients and greater satisfaction with patients and families because their care is handled from start to finish by a dedicated team who is there when patients need them.

The quality of life benefits are also very attractive: comparable income to the private practice model with a predictable work pattern, manageable shifts that allow the surgeon to plan his or life and the freedom to know your patients are receiving excellent care, even in your absence, has had appeal to many.

For example, the surgeon who is thinking of retirement may re-consider when he or she can alleviate the stress of a busy private practice and have control over a schedule. The young physician seeking the camaraderie and team-based care of residency can continue to get the support he or she needs.

Keeping these professionals active is very important in dealing with the impact of the current shortage of surgeons. Even mid-career surgeons who want to have more regularity in their schedules for growing families or other pursuits can have both a satisfying career and the quality of life they want. The acute care surgery model offers the attractions of predictable schedules with the challenge of meeting constantly changing patient needs.

Finally, there is the excitement of being part of something new and revolutionary. The acute care surgeon is a pioneer. Every day we are forging a new path—delivering an innovative solution that transforms the lives of our patients and keeps us engaged in our profession. Because we work in teams, there is always back-up and qualified professionals there for any patient need. We’re able to standardize care, which is a major reason why outcomes improve. Patients are delighted to have this attention, communication, and security knowing that they are being overseen 24/7.

The unspoken revolution currently taking place in American surgery is addressing the surgical shortfall while offering the promise of improving patient care and safety, and the potential to increase our own satisfaction as dedicated surgeons. The acute care surgery model is defining the next decade in emergency surgery care and we’re here to see it through.

In my last blog, I talked about the Acute Care Surgery space, highlighting where it is headed, specifically as we seek to attract new surgeons to the profession.

But in an era of surgical shortages, where millions of Americans don’t have ready access to a good surgeon, getting new physicians to join the profession is just Step 1. Step 2 is finding ways to encourage existing surgeons to stay in practice, to avoid burnout and the move to other specialties that may offer greater professional rewards and a more manageable quality of life.

Let’s start by looking at how acute care surgeons help hospitals, patients and private practice surgeons improve their practices.

The acute care surgery model offers a solution to ensure 24/7 availability in the hospital, while providing benefits to all surgeons, and most importantly, to the patients. Focusing solely upon emergency surgical care in the hospital, we care for patients who need emergency general surgery. We are available to immediately respond to any emergency surgery need from the ED. And because we are there, a community surgeon doesn’t have to get a call requiring them to come in at 2 a.m. to care for a car crash victim.

We provide all patient care including consults, covering a full-service follow-up clinic to manage those patients requiring care post discharge and perform all surgical procedures during our shift.

In some acute care surgery programs, the surgeons (all board-certified in general surgery, with many holding additional certificates, such as surgical critical care) take 24-hour shifts with the next day off. They are available to handle in-house emergencies and guarantee a response to the ED within 30 minutes when needed. In addition to surgeons, a nurse practitioner (NP) and/or physician assistant (PA) is often part of the team, rounding with the surgeons each day, coordinating care for patients and communicating with the family. They are key members of the team and play an important role in patient communication, treatment and ensure effective hand-off of the patient back to his or her primary physician.

We are a true team, experienced in the latest surgical techniques and procedures. One area of focus is the use of guidelines to ensure we provide optimal care before, during and after surgery.

When an entire surgical team is incentivized to agree and commit to evidence-based practice management guidelines, variations in care are significantly reduced. Standardizing care has repeatedly been proven to improve efficiencies and outcomes, as well as lower costs. For example:

• Reduced ED turnaround times.
• Operations are performed on a timelier basis.
• Shortened LOS, with decreased complications.

While there are many benefits to an acute care surgery model, as it is still relatively new, there are concerns and important issues to discuss with our colleagues and partners. One of the concerns is the possible erosion of private practices in the community.

However, as numerous published works have shown, this doesn’t have to be the case. In fact, an article in the Journal of the American College of Surgeonsⁱ demonstrated that despite the introduction of a busy Acute Care Surgery team, the volume of cases for private practice surgeons remained the same.

In some instances, relief from ED call has allowed some private practice surgeons to increase their surgical volume; as well as enjoy a more stable office and personal life. In short, the presence of an Acute Care Surgery team enables them to perform more elective surgery cases and can help improve their overall quality of life.

My last blog of this series will address additional advantages this model brings to surgeons.

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ⁱ Journal of the American College of Surgeons. “Acute Care Surgery: Impact on Practice and Economics of Elective Surgeons.” Preston R. Miller, M.D., FACS, et al. April 2002. (http://www.journalacs.org/article/S1072-7515(12)00073-7/abstract)

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Whether it’s a collision or an emergency appendectomy, acute care surgeons, take care of the sickest patients in the hospital. We are hospital-based surgeons who, as part of a dedicated and collaborative team, provide care to patients during their most critical times of need, 24/7.

Because we are highly trained and are at the ready when patients need us most, we help to save lives and improve outcomes.

Acute care surgery is an evolving specialty encompassing the components of trauma, critical care, and emergency general surgery. The specialty addresses one of the biggest transformations happening in the ever-changing environment of surgery. It is taking on new responsibilities for emergency surgical care, and increasing the ability to care for these patients as new techniques are developed, in the face of advancing technology. Acute care surgeons are pioneering a new approach to in-patient surgery.

The Surgical Shortage versus the Demands of Inpatient Surgery Today

Why is this transformation necessary? Patients’ emergency care can be compromised by physician shortages in the surgical suite and increased volumes in the ED, a situation that has been escalating over the last several years. In fact, more than 10 years ago, a Robert Wood Johnson Foundation (RWJF) survey found that two-thirds of EDs do not have enough surgical call coverage to meet the demand for emergency surgical care.ⁱ This ongoing problem has only grown worse. A subsequent study by RWJF of on-call specialty care found that three-quarters of EDs had inadequate surgical call coverage.ⁱⁱ

Now, with millions of Americans obtaining health coverage for the first time, hospitals across the nation are reporting that even more patients are presenting to their emergency departments, in part because these newly insured patients have trouble finding primary care physicians.ⁱⁱⁱ Taking care of these patients is exacerbated by the growing shortage of surgeons. Estimates are that there will be a shortage of 46,100 surgeons and medical specialists by 2020.^iv

Clearly, the old, traditional method of surgeons in private practice taking a call, just will not work today. There aren’t enough surgeons. Those in private practice often want to focus on their practices which are intensive enough without the “nuisance of being on call.”^v Furthermore, the demands of patient care today require responses in minutes, not hours. As the acuity of patients who are hospitalized rises, so too is their need for responsive, immediately-available teams to provide acute care surgery. Finally, within the hospital environment, all departments are required to step up their timeliness and performance in delivering care according to best practices.

A New Acute Care Surgery Model

The acute care surgery model initially arose in the academic environment as a solution to manage these patients with physiologic needs similar to trauma patients for whom access to 24/7 care could make a difference in their outcome.^{vi, vii, viii, ix, x, xi} With time, with the creation of Acute Care Surgery Fellowships and the American College of Surgeons’ (ACS) vision to bring together surgeons, resources and the infrastructure to provide 24/7 care for surgical emergencies, a new model emerged that is gaining acceptance across the nation. Implementing the acute care surgery model has proven very beneficial to patients with emergency surgery needs, reducing adverse outcomes and increasing overall positive results, improvements that are attributed to the focused care of these patients.^xii

As noted, the evolving specialty of acute care surgery encompasses trauma, critical care, and emergency general surgery. Arising to satisfy the need for emergency call coverage, acute care surgeons help speed up, standardize and improve patient care overall from the ED. The rise of on-site hospital surgeons, often acute care surgeons and frequently referred to as surgicalists, is helping mitigate the problems created from the increasingly limited number of surgeons who provide this care in the community.

Recognizing the growing national need for acute care surgeons, there are now 18 fully accredited AAST Acute Care Surgery fellowship programs focusing on this track. Acute care surgery now offers surgeons coming out of residency a new career path, one that acknowledges and rewards their skills and commitment. In an era of surgeon shortages, we must find ways to attract the best and brightest to this profession; this is an important step toward that goal.

Stay tuned for my next blog on this topic which addresses the advantages this model brings to hospitals and patients.

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ⁱ American College of Emergency Physicians. “On-call Specialist Coverage in U.S. Emergency Departments, ACEP Survey of Emergency Department Directors.” September 2004. (http://www.acep.org/workarea/DownloadAsset.aspx?id=8974)
ⁱⁱ Robert Wood Johnson Foundation. “Severe Shortage of Surgical Specialists Plagues Nation’s Emergency Departments.” Mitesh Rao, M.D., M.H.S., et al. February 10, 2011. (http://www.rwjf.org/en/library/articles-and-news/2011/02/severe-shortage-of-surgical-specialists-plagues-nations-emergenc.html)
ⁱⁱⁱ California HealthLine. “Many Newly Insured Individuals Struggle to Find Primary Care Docs.” December 8, 2014. (http://www.californiahealthline.org/articles/2014/12/8/many-newly-insured-individuals-struggle-to-find-primary-care-docs)
^iv Bonnie Darves. “Physician Shortages in the Specialties Taking a Toll.” The New England Journal of Medicine Career Center. March 2011. (http://www.nejmcareercenter.org/article/physician-shortages-in-the-specialties-taking-a-toll/)
^v Deborah Gesensway. “Surgicalists: Why Aren’t They in Your Hospital?” Today’s Hospitalist. January 2015. (http://www.todayshospitalist.com/index.php?b=articles_read&cnt=1977)
^vi Derlet RW, Richards JR. “Overcrowding in the nation’s emergency departments: complex causes and disturbing effects.” Annals of Emergency Medicine. 2000; 35:63–68.
^vii Lewin Group. “Emergency Department Overload: A Growing Crisis. The Results of the AHA Survey of Emergency Department (ED) and Hospital.” 2002.
^viii Asplin BR, Magid DJ, Rhodes KV, et al. “A conceptual model of emergency department crowding.” Annals of Emergency Medicine. 2003; 42:173–180.
^ix Scherer LA, Battistella FD. Trauma and emergency surgery: an evolutionary direction for trauma surgeons.” Journal of Trauma. 2004; 56:7–12.
^x Kim PK, Dabrowski GP, Reilly PM, et al. “Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service.” Journal of the American College of Surgeons. 2004; 199:96 –101.
^xi Capacity. Available at: http://www.hospitalconnect.com/aha/press_roominfo/content/EdoCrisisSlides.pdf. Accessed Online May 5, 2006.
^xii “Sustainability and Success of the Acute Care Surgery Model in the Nontrauma Setting.”Journal of the American College of Surgeons. Volume 219, Issue 1, Pages 90–98. (http://www.journalacs.org/article/S1072-7515(14)00220-8/fulltext)

Millions of Americans don’t have access to a qualified surgeon in the event of a trauma-related medical emergency—a problem that is especially acute in rural areas. Recently, Anne Platt, FACHE and CEO of Sutter Amador Hospital, and I made a presentation at the American College of Healthcare Executives’ 2016 Congress on Healthcare Leadership on this topic.

Thousands of hospitals nationwide face the twin challenges of recruitment and retention of qualified surgeons for acute and trauma care. While the issue is especially prevalent in rural areas, it affects urban and suburban hospitals as well. Plus, the issue of recruiting surgeons is compounded by aging surgeons (average age is now over 50), while fewer graduates are entering critical care residencies.

The implications of the looming surgical shortage do not bode well for hospitals or patients.

Over-burdened surgeons are increasingly pushing back. Hospitals are constantly struggling to recruit, retain and maintain surgeons and their Trauma Center status. And, patient care can potentially suffer.

Like other hospitals in rural areas, Sutter Amador Hospital faced the increasingly difficult issues of recruiting and retaining enough surgeons to serve the needs of its community. The hospital’s goal was to find a viable solution to ensure that both its patients and the surrounding community had access to high quality, 24/7 acute care surgery services. It also wanted a long-term solution to help it avoid losing market share while ensuring that the solution aligned with its mission, goals, and culture.

Ultimately, the hospital opted to partner with Surgical Affiliates and adopted our surgicalist hospital model to solve its problems and address its needs. With this long-term solution, which is reproducible in other hospitals, the focus is on the creation of a team approach, coordinated and supported with processes, systems and skilled advanced practitioners (nurse practitioners and physician assistants). Surgeons are always available—24/7—for consults and acute care surgeries, while advanced practitioners support the surgical team by managing the clinic, follow-up care, and care coordination.

A comprehensive surgical hospitalist program benefits rural hospitals, especially for solving the challenges of recruiting surgeons and improving quality of patient care. Plus, the model can work for hospitals in urban environments, providing consistent surgical call coverage and improving patient safety and outcomes, while boosting results throughout the hospital.

From 2012 to 2014 Sutter Amador has:

• Increased all general surgery cases from 129 to 266
• Decreased Average Length of Stay from 6.45 to 5.26
• Increased Case Mix Index from 2.0 to 2.34

As a result, the hospital has generated a positive ROI. By applying the acute care surgery model, which applies disciplines in trauma surgery to general surgery, hospitals can better achieve consistent, evidence-based care and improved clinical outcomes.

With increasing demand, aging of surgeons and the challenges of recruitment in many markets, the nation’s hospitals will continue to struggle to find solutions for acute and trauma surgical care. A very viable solution is to partner with outside organizations such as Surgical Affiliates to build surgicalist programs. Our model delivers a programmatic approach to general emergency surgery providing access to high-quality emergency surgical care 24/7.

>Our Acute Care Surgery Model (also referred to as surgical hospitalist or surgicalist programs) delivers a programmatic approach to general emergency surgery providing access to high-quality emergency surgical care 24/7. By applying the acute care surgery model, which applies disciplines in trauma surgery to general surgery, we are able to achieve consistent, evidence-based care and improved clinical outcomes for our patients. Our comprehensive Acute Care Surgery program delivers a dedicated team of surgeons led by a medical director whose sole practice is treating emergency surgery patients. This model addresses widespread emergency department challenges and improves efficiencies throughout the hospital but more importantly improves patient outcomes.

We found that after implementing our Acute Care Surgery Model, complications were dramatically decreased. Results of a five-year study published in the Journal of the American College of Surgeons showed:

• Complications decreased 43%
• Length of stay decreased 12%
• Hospital costs decreased 31%
• Readmission rates were down—while LOS significantly decreased, readmissions did not increase
• Overall hospital CMI improved
• Annual savings was $2 million

Additionally, this model produced shorter hospital lengths of stay and lower costs.

• Appendectomies—an average 27.8% decrease in total hospital costs; average LOS decreased 36.7%; the number of appendectomies increased 15.8%
• Laparotomies—outcomes from in-hospital morbidity declined 49%
• Cholecystectomies— in-hospital morbidity declined 83%; an average 14% decrease in total hospital costs; the readmission rate decreased 69.6%; number of cholecystectomies increased 29.8%

Another study reported that the national average cost for cholecystectomies per case is $15,650¹, yet after the Acute Care Surgery model was applied at the facility referenced above, its cost per case for the same procedure was $8,432, representing a 46% savings.

These results, which have proven sustainable and can be implemented in all types of hospitals, are an outcome of improving the timeliness of care, implementing patient care guidelines and protocols to reduce variation. For more information, visit our Hospitalist Program Calculator or Surgical Hospitalist Program page.

¹ Stey A, Brook R, Needleman J, et al. Hospital Costs by Inpatient. J Am Coll Sug 2015:220:207-217

Hospitals are searching for a workable system for 24/7 ED emergency surgery coverage. Unfortunately for the hospitals, there’s a shortage of surgeons. This, combined with many surgeons’ frustration with ED call coverage and their desire to have more regular hours, is exacerbating the problem. It’s often a major source of conflict between hospital administrators and surgeons, which can potentially negatively impact the quality of care.

That’s one of the reasons Surgical Affiliates was founded: to be the solution to this problem. Our surgicalist model delivers proven, high-quality, 24/7 coverage for patients needing emergency surgeries, while offering healthcare professionals (surgeons, NPs and PAs) an option they never thought was possible: having a challenging and rewarding career AND time for personal priorities. In addition to general surgery, our surgical hospitalist program encompasses specialties such as trauma, and orthopedic surgery.

Here are a few reasons to consider becoming a member of the Surgical Affiliates team:

• You can be part of a new and satisfying field as a surgicalist.
• You can be in a practice unlike any you’ve known, with the professional satisfaction of doing what you were trained to do.
• You can focus on your patients while all of the management services are handled for you.
• You can have dependable and regular schedules that afford you the time and benefits to attain work-life balance.
• You can enjoy your free time with the security of knowing that your patients are receiving the highest quality of care from your practice partners who are as committed to quality patient care as you are.

The hospitalist lifestyle and career afforded by our model is what enables us to bring teams of high quality and talented healthcare personnel to our partner hospitals. When we look for healthcare professionals to join our team, in addition to the usual criteria of board certifications, etc., we seek out people who are passionate about their job and the patients’ well-being, who have a record of achieving high patient satisfaction scores, who are involved in their community and who thrive on working in a team-oriented environment. We look for top people because we want the doctors in our partner hospitals to say they “want their family members to be treated by our doctors.”

For surgeons especially, Surgical Affiliates’ model offers more options. For example, the surgeon who may be thinking of retiring may re-consider with the option of a more flexible schedule on the surgical hospitalist team or a private practice without the stress of taking ED call. Younger surgeons may thrive on the challenge of doing emergency surgeries while not worrying about patient insurance or the billing and enjoying the lengthier blocks of free time for family or other pursuits.

We are always looking for:

• General surgeons
• Trauma surgeons
• Orthopedic surgeons
• Nurse practitioners
• Physician assistants

Why not join us and be part of a team that is transforming emergency surgical care across the U.S.? Here’s a link so you can learn more about surgical hospitalist careers: https://www.samgi.com/join-our-team/

>Recently, for the fifth time, Sutter Medical Center, Sacramento (SMCS) was named one of the Top 100 Hospitals in the U.S. by Truven Analytics. It was recognized, along with the other hospitals selected, for consistently delivering outstanding quality of care, satisfaction and community value at a reasonable cost.

For the first time, SMCS also earned the Top 100 Hospitals Everest® Award—one of only 17 hospitals in the nation and the only hospital in California to simultaneously set the national benchmark for both “balanced excellence in a single year” and “greatest improvement over five consecutive years.”

Truven selected the hospitals based upon an independent analysis of public data. The criteria used included both financial benchmarks (hospital profitability, as well as Medicare per beneficiary spending) and clinical measures; for example, 30-day readmission and mortality rates metrics.

Surgical Affiliates Management Group’s surgicalist program was one component that helped SMCS achieve this major recognition. Our collaborative surgical hospitalist program boosted performance throughout the hospital, improved patient care and reduced costs, as documented in a five-year study undertaken by SMCS and Surgical Affiliates, which was published in the prestigious peer-reviewed Journal of the American College of Surgeons. The study validated that surgical hospitalist programs improve key hospital performance metrics. For SMCS this included:

• Decreasing length of stay by 12%
• Reducing complications by 43%
• Lowering costs by 31%—a total of $2 million in a single year

According to Jean Chenoweth, senior vice president at Truven Health Analytics, if all Medicare inpatients received the same level of care as those treated in the award-winning facilities:

• More than 164,000 additional lives could be saved.
• Approximately 82,000 additional patients could be complication free.
• More than $6 billion could be saved.
• The average patient stay would decrease by nearly half a day.
• And if the same standards were applied to all inpatients, the impact would be even greater.

We’re delighted that Sutter Medical Center, Sacramento has once again been honored as one of the nation’s top hospitals. If you are interested in learning more about how our partnership with SMCS helped accomplish these results, please read our most recent case study “The Verdict Is In: Surgical Hospitalist Programs Deliver Improved Results throughout the Hospital.” To request a copy, please visit www.samgi.com