Defining surgical critical care as an integrated specialty

PurposeAmong general surgeons, resistance to incorporating critical care specialists into the mainstream of surgical critical care is well documented. Loss of control, fragmentation of care, added cost, and the abdication of expertise are frequently cited as objections to this approach. In 1992, we began to explore the feasibility of developing a fully integrated, multidisciplinary surgical critical care program, structured to avoid these pitfalls. The conversion from a traditional nonintegrated surgical model was completed in 1993. This report summarizes the structural changes and results of this effort.MethodsThe Surgical Critical Care Service was converted from a combined trauma/critical care service into a multidisciplinary section of the Department of Surgery, composed of 12 full-time faculty (7 surgeons, 5 nonsurgeons). All (surgeons and nonsurgeons) are active full-time members of the department with a director (nonsurgeon) and a residency program director (surgeon) who report to the chairman of the department. Patient care is both vertically (surgical team) and horizontally (intensive-care-unit team) integrated with a surgical/critical care resident functioning as the key crossover member of both teams. Educational programs are organized and administered by the residency program director with faculty choice based on ability rather than training background. A work group composed of the chairman, key section directors (anesthesiology, critical care, trauma, burns, and cardiac surgery), and the assistant vice president of nursing meet monthly to provide global direction and resolve differences of opinion.ResultsTension between general surgeons and critical care specialists has been eliminated. Objective performance parameters have significantly improved since the conversion. Resident evaluations and American Board of Surgery In-Service Training Examination (ABSITE) performance remained constant or improved after conversion.ConclusionThe development of a multidisciplinary critical care program based in the Department of Surgery relieves professional tensions, improves the quality of care, and enhances educational and research opportunities for both critical care and general surgery residents.     

Pediatric surgical workload during the past decade: impact on clinical activity and hospital finance at a children's hospital

PURPOSE: The authors hypothesized that there are significant differences in clinical effort among the faculty of the various departments at an academic Children's Hospital, and that the clinical workload of surgeons has increased over the past decade. METHODS: A retrospective analysis of clinical practice and financial performance of the five departments (anesthesiology/critical care medicine, pathology, pediatrics, radiology, and surgery) at the Children's Hospital of Philadelphia from 1987 to 1997 was performed including clinical activity parameters (admissions, discharges, clinic visits), departmental faculty rosters, number of operations for the department of surgery as a whole and for individual surgeons in each pediatric surgical specialty, and professional and hospital financial data. RESULTS: Pediatric surgical specialists represented 15% of the total full-time physicians throughout the decade. In 1997, surgeons were responsible for 29% of hospital admissions, 28% of total outpatient visits at all clinical care sites, 37% of total professional fee revenue, 39% of hospital-based revenue, and a substantial portion of the hospital margin. Compared with 1987, the department of surgery in 1997 had a 60% increase in outpatient visits and a 58% increase in total operative case load (10,265 to 16,266). In terms of individual surgeon's workload during the decade, the outpatient visits per surgeon increased 45% and the operations per surgeon increased 27%, yet total reimbursement per surgeon slipped 16%. CONCLUSIONS: For the Children's Hospital that was studied, pediatric surgical specialists are doing more clinical work compared with 10 years ago, which may impact teaching, research, and administrative responsibilities. Surgeons have a greater responsibility than nonsurgeons for the hospital's clinical activity and financial health.     

Assessment of the emergency surgical patient

It is well known that emergency surgical patients have a higher risk of postoperative morbidity and mortality than those having elective procedures. A systematic preoperative assessment forms an important part of identifying risk factors and reducing their impact. Patients may require simultaneous resuscitation and assessment. Further deterioration in the patient's condition must not occur as a result of delays in decision making or awaiting results of investigations. A risk assessment score is useful for both surgeons and patients to provide information on possible postoperative outcomes. It will aid discussion for informed consent and guide planning of staffing for surgery and postoperative care location.     

Access to hand surgery emergency care

Limited access to hand surgical care in the emergency room appears to be a problem in north Florida and probably other parts of the country, as well. In this study, hand surgeons in 3 major cities were contacted to determine what on-call services they provide for hospital emergency departments in their areas. Additionally, hospitals that accept trauma patients were queried about how many hand surgeons they have on staff and if there were times when no surgeon was on call and how they managed hand trauma when that problem is encountered. Results showed that although there are numerous hand surgeons in each city, there were many times in which a hospital would have no hand surgeon on call for an emergency. Our data suggest that on a regionally selective basis, hospital emergency facilities are deficient with respect to the availability of appropriate specialists for those patients requiring emergency hand procedures.     

Analysis of surgical participation in the Advanced Trauma Life Support course. What are the goals and are we meeting them?

Advanced Trauma Life Support (ATLS) course records spanning 4 years were examined and American College of Surgeons members in Washington State surveyed to gain further information on ATLS course participants, skills utilization, and hospital credentialing. Thirty-seven (9.7%) of 382 course participants were trained general surgeons, 56 (14.7%) were surgical residents, and 12 (3.1%) were surgical specialists. One hundred thirty-six (35.6%) of the participants were primary care physicians and 115 (30.1%) were emergency physicians. Surgical residents, primary care physicians, and emergency physicians tended to be overrepresented in ATLS courses in comparison with their general distribution. Fully trained surgeons and surgical specialists were underrepresented. Course participants represented 3.8% of all physicians involved in patient care in the state. Only 6.4% of all active general surgeons in the state were participants, while 39% of active emergency physicians participated. The successful completion rate was 94% (98% for surgeons and 92% for nonsurgical physicians). Thirty-one percent of all American College of Surgeons survey respondents (31% of urban practitioners and 21% of rural practitioners) reported current ATLS qualification. Advanced Trauma Life Support qualification was reported by 31% of respondents as a requirement for taking trauma/emergency department call. Surgeons with a preference not to treat patients with trauma were less likely to have ATLS qualification. More than half of those who reported ATLS qualification had not performed a tracheal intubation, cricothyroidotomy, pericardiocentesis, or emergency department thoracotomy in the previous year. Participation of surgeons in ATLS courses is low, particularly among rural practitioners. Impetus for participation appears related to requirements for hospital staff credentialing and preferences for treating patients with trauma. Performance of procedures taught in the course is rare. Strategies to increase participation need to be formulated and implemented.     

A surgeon in the ICU: An equal “team-mate” or an “intruder”?

Demand for critical care services is increasing. The role of surgeons in intensive care units (ICUs) provides specific insights and perspectives concerning the care of surgical patients, sometimes not fully appreciated by the non-surgical practitioners caring for these patients. The training and education of surgeons is becoming more complex, fragmented, and lengthy. The knowledge-based skills required to manage critically ill patients are also becoming more extensive. However, surgeons need to spend focused attention on how best to train and educate upcoming surgical trainees in regard to the principles of critical care medicine; educational programmes could be developed for better surgical education within the basic residency and surgical critical care programmes. The critically ill patient needs this focused attention as does the specialty of surgical critical care medicine.     

Analgesic administration prior to surgical evaluation for acute appendicitis

BACKGROUND: The attitudes of surgeons and nonsurgeons regarding the administration of pain medicine prior to arriving at a surgical diagnosis are changing. It is common practice to administer narcotic analgesics prior to a general surgeon's evaluation. Several studies have advocated the safety of this practice in the emergency department. Many of these studies are flawed by inclusion of many patients who did not have a surgical illness. Our study examined the practice of narcotic administration in patients determined to have appendicitis who underwent operation. METHODS: We retrospectively reviewed 75 consecutive appendectomies. Emergency department records and in-patient charts were reviewed to assess differences in 2 groups of patients: those who received narcotic pain medicine and those who did not. Specific outcome parameters were reviewed such as time in hospital, time to the operating room, and complication rate. We also created a scoring system for the physical examination to attempt to quantify a difference between the groups. FINDINGS: Overall, 75 patient charts were reviewed. Nine patients were excluded. There was no statistically significant difference in the 2 groups in regard to time in hospital, time to operation, complication rate, perforation rate, or negative appendectomy rate. The physical examination scoring system did show a difference between those who got pain medicine and those who did not, but failed to show a difference between examiners after pain medicine was given. CONCLUSIONS: There does not appear to be a difference in hospital stay, time to the operating room, complication rate, negative appendectomy rate, or perforation rate in patients who received pain medicine prior to a surgeon's evaluation and those who did not in this retrospective review.     

The trauma surgeon in the emergency department,a life saver ?

Background: The golden age of trauma has gone. 25 years ago the trauma surgeon was the life saver in the emergency department. He was the leader of the resuscitation team and made the important decisions in the process. Nowadays different factors have diminished the role of the trauma surgeon.

Discussion: Thanks to the decrease of severely injured patients in Europe and the advances in diagnostic and treatment possibilities the approach to trauma victims is less often operative. Furthermore, the uprising of emergency medicine specialists has taken many tasks out of the hands of the trauma surgeon. However, experienced trauma surgeons can do both critical care and acute care surgery and should be included in the decision-making process in the emergency room. Conclusion: Although the trauma surgeon often is no longer the captain of the ship in the emergency department, he can still play an important role in trauma care. They still are life savers.

Abbreviations: CAT-scan: computed axial tomography . CT: computed tomography; HIV: Human Immunodeficiency Virus.     

Penetrating thoracic trauma

A penetrating injury to the chest may be one of the more feared crises to face the surgical trainee. The patients are usually unstable, often uncooperative, and the solution is usually expedient surgery and one cannot procrastinate by requesting a CT scan. Rarely can the situation wait till a cardiothoracic surgeon arrives. In a major trauma centre, where the call from ambulance control will have drawn an experienced team to the resuscitation area, a well-rehearsed operative resuscitation will ensue, performed by surgeons whose main field of expertise may be emergency medicine, general surgery or even orthopaedic surgery. Due to the urgency of such cases, they may also present to any hospital with an A & E department, mandating that all doctors working in emergency care have a knowledge of penetrating injuries and the emergency surgery required to control their consequences. This article aims to help the surgical and emergency medicine trainee provide either definitive care or stabilization of the patient until specialist help arrives.     

Practice of critical care medicine in academic surgical centers

Chairmen of academic surgical departments in the United States and Canada were questioned as to the administration, practice, and education of critical care medicine in their university hospitals. Sixty-one percent of departments had surgeons as surgical intensive care unit (SICU) directors, 67% preferred to have a surgeon as director, and 93% of those who had a surgeon as director were in favor of that arrangement. Eighty-four percent felt that involvement in the ICU did not detract from an individual's operating ability. Despite this perceived manpower demand, only 9.4% of all surgical ICUs and 3.4% of those ICUs with a surgeon as director had fellowships in critical care medicine. Rotations through the SICU were available in only 55% of programs and these tended to be only 1 or 2 months as a junior resident. These data indicate a need to increase the amount of training available to surgical residents if the desire to have surgeons direct our surgical intensive care units is to be fulfilled.     

Surgeons' attitudes about communicating with patients and their families

CONTEXT: Surgeons face difficult communication challenges with patients and their families. There is a need for improved education in communication skills, especially in giving bad news. Understanding surgeons' attitudes is the first step in designing effective education programs. OBJECTIVE: To determine surgeons' self-assessment of competence, rating of importance, and perceived need for training in communication skills relevant to patient care. DESIGN: Anonymous self-report mail survey of demographic information and attitudes toward 12 patient care-related communication skills. SETTING: San Diego County, California, a geographically distinct area of close to 3 million inhabitants receiving health care from over 6000 physicians. PARTICIPANTS: A total of 351 (43.4%) respondents from the 833 surgical specialists in the San Diego County Medical Society list of member and nonmember physicians. MAIN OUTCOME MEASURES: Measurement of surgeons' attitudes toward self-perceived competence, importance, need for training in the communication skills, and the influence of age, duration of practice, and surgical-specialty on attitudes. RESULTS: Most respondents rated their competence high except in 3 skills relating to a patient's death. They found all skills important and indicated a need for training in them. Younger surgeons rated their competence and the importance significantly lower in the 3 skills relating to a patient's death (p < 0.05). Critical care surgical specialists rated their competence and the importance higher in skills relating to breaking bad news and a patient's death than did the non-critical care group (p < 0.05). Older surgeons and critical care specialists also indicated a higher level of support for training in these skills. CONCLUSION: These results suggest that surgical specialists rate themselves as competent in effective communication, believe in its importance, and agree with the need for training. An organized approach to training in interaction skills, especially in giving bad news, is warranted.     

Lack of emergency hand surgery: discrepancy between elective and emergency hand care

Wrist, hand, and finger trauma are the most common injuries presenting to emergency departments. Shortage of emergency hand care is an emerging problem, as on-call hand coverage declines. This study evaluates the availability of elective and emergency hand surgery services in Tennessee, with the use of telephone surveys administered to emergency department and operating facility management. One hundred eleven Tennessee hospitals completed the surveys (93% response rate). In all, 77% of hospitals offer elective hand surgery, 58% offer basic emergency hand services, 18% offer occasional hand specialist call coverage and only 7% of hospitals have 24/7 hand specialist call coverage. Hospitals with hand specialists have significantly more payer charges from commercial insurance than hospitals without hand specialists (26.1% vs. 16.1%, P < 0.001). Our results strongly support the need for increased emergency hand coverage. Solutions include creating multihospital coordinated call schedules, increasing incentives for call coverage, and training more hand specialists.     

Sub-specialization in general surgery: the problem of providing a safe emergency general surgical service

BACKGROUND: The increasing subspecialization of general surgeons in their elective work may result in deskilling and create problems in providing expert care for emergency cases. To evaluate the size of the problem this study determined how often complex emergency surgical cases are treated by general surgeons working outside their own elective subspecialty. METHOD: In a district general hospital in the south of the UK serving a population of 550 000 where there is almost complete subspecialization within general surgery, 1554 patients having emergency general surgical operations were studied in a one-year review. The time an operation occurred, the seniority of the operating surgeon, the subspecialty interest of the consultant responsible for the case compared with the specialist nature of the operation was determined. RESULTS: Of 1554 patients having emergency general surgical operations, 23% (352/1554) were of a high category of complexity. Ninety were vascular procedures and were dealt with by specialist vascular surgeons on a separate rota. Of the remaining 262 operations, 78 (30%) did not match the subspecialty of the consultant surgeon responsible for their care; 56 (72%) of these occurred out of hours of which 14 (18%) had a consultant surgeon present and scrubbed in the theatre; one per month of the study. Seventy-three percent (57/78) of these were complex colorectal operations. CONCLUSION: The mismatch between the subspecialist elective interests of the consultant general surgeon and out of hours specialist major surgery needing consultant involvement occurred infrequently, and was mainly due to major lower gastrointestinal cases managed by upper gastrointestinal and breast surgeons. This has important implications for the future training of general surgeons and the provision of an emergency nonvascular general surgical service.     

Positive impact of a breast-health triaging system on breast-care access and physician satisfaction

OBJECTIVE: Minority patients are at risk for delayed breast cancer treatment. Using nonsurgical breast specialists could improve access but requires appropriate referral to ensure prompt cancer care. Our objective was to evaluate a referral triage system in a combined medical/surgical breast health program (BHP). METHODS: A triage system based on imaging findings, examination, and patient age was instituted. An advanced practice nurse managed referrals and a prospective database. Referring providers were surveyed after 2 years. RESULTS: From 2003 to 2006, 4,840 referrals were made to surgeons (57%) and nonsurgeons (43%). Breast cancers were found in 8.5% of patients. Referral error occurred in 4 cancer patients (.1%). BHP-referred patients had significantly shorter times to surgical appointment (10 days) than non-BHP referrals (45 days). A referring provider survey indicated 96% satisfaction. CONCLUSIONS: A breast-care triage system expedited cancer care resulting in physician satisfaction and increased referrals.     

The potential role of pediatric surgeons in adolescent medicine

Adolescent medicine is a rapidly growing and an increasingly recognized discipline. Based upon our 6-yr experience with an active Division of Ad'olescent Medicine we believe that the adolescent's surgical diseases also are unique problems deserving of special interest. While other surgeons have assumed responsibility for care in many of the adolescent programs, the pediatric surgeons' background and training especially qualify them for a major role in this area. It is a stimulating and gratifying opportunity to which they should address themselves.     

The consequences of obesity on trauma, emergency surgery, and surgical critical care

The era of the acute care surgeon has arrived and this "new" specialty will be expected to provide trauma care, emergency surgery, and surgical critical care to a variety of patients arriving at their institution. With the exception of practicing bariatric surgeons, many general surgeons have limited experience caring for obese patients. Obese patients manifest unique physiology and pathophysiology, which can influence a surgeon's decision-making process. Following trauma, obese patients sustain different injuries than lean patients and have worse outcomes. Emergency surgery diseases may be difficult to diagnose in the obese patient and obesity is associated with increased complications in the postoperative patient. Caring for an obese patient in the surgical ICU presents a distinctive challenge and may require alterations in care. The following review should act as an overview of the pathophysiology of obesity and how obesity modifies the care of trauma, emergency surgery, and surgical critical care patients.     

The anesthesiologist's role in the French emergency medical system

The present system of French emergency medicine and its philosophy were described from my experience at SAMU (service d'aide medicale urgente). Three factors of emergency medicine; pre-hospital care, emergency transport and emergency information service are managed by anesthesiologists. Anesthesiologists on duty at the tele-medicine center give medical team instructions to start at once. The team is composed of an anesthesiologist, a nurse and an ambulancier. They start to give intensive care medicine to critically ill patients on the spot. The philosophy of SAMU is that doctors should go out of the hospital. Anesthesiologists in the area organize the emergency medical system in France.     

Care of the critically ill patient

The care of critically ill patient within the intensive care unit requires a multidisciplinary approach. An understanding of the main principles of intensive care medicine is essential for surgeons, both for participating in the management of their own critically ill patients and also because surgical complications of critical care are well recognized. This article describes the main principles of intensive care medicine within the context of the COVID-19 pandemic, giving an overview of a systematic approach to assessment and treatment of organ dysfunction, and highlights some of the complex ethical and organizational challenges.     

The surgical hospitalist: a new model for emergency surgical care

BACKGROUND: Quality of acute surgical care in the US is threatened by a shortage of surgeons performing emergency procedures because of rising costs of uncompensated care, liability concerns, declining reimbursement, and lifestyle considerations. In July 2005, we restructured the general surgery service at our medical center into a hospitalist model to improve patient access to surgical care. STUDY DESIGN: We hypothesized that a surgical hospitalist program could improve timeliness of care, emergency department (ED) efficiency and physician satisfaction, resident supervision, continuity of care, and revenue generation. We reviewed our program after 1 year, including patient demographics, diagnosis, and time to consult. RESULTS: Three surgical hospitalists cared for 853 patients during 1 year. Patients ranged from 17 to 100 years of age and presented with abdominal pain (66%), infection (18%), malignancy (6%), hernia (4%), and trauma (3%). Fifty-seven percent of consults originated from the ED; 8% came from other surgeons. Mean time to consult was 20 minutes. A survey of ED physicians reported shorter ED length of stay, better patient satisfaction, improved professionalism and resident supervision, and better overall quality of care. Average waiting time for patients with acute appendicitis to undergo operation was reduced from 16 +/- 10 hours to 8 +/- 4 hours (p < 0.05). Forty-two percent of consults resulted in an operative procedure, and revenue increased as the number of billable consults rose by 190%. CONCLUSIONS: The surgical hospitalist model provides a cost-effective way for general surgeons to provide timely and high-quality emergency surgical care and enhance patient and referring provider satisfaction.     

急诊危重症患者院内转运安全管理最佳证据总结

目的 检索国内外急诊危重症患者院内转运安全管理的相关证据,对最佳证据进行总结,为规范急诊危重症患者院内转运提供参考。 方法 系统检索国内外数据库关于急诊危重症患者院内转运安全管理的相关证据,由2名研究员对文献质量进行独立评价,结合专业人士的判断,对符合标准的文献进行资料提取。 结果 共纳入13篇文献,其中临床决策1篇、证据总结3篇、指南2篇、系统评价4篇、专家意见/专家共识3篇。最佳证据共30条,包括转运设备日常管理、风险评估、转运前准备、转运中监测与治疗、交接与记录、质控与培训6个方面。 结论 本研究总结的最佳证据可为制定急诊危重症患者院内转运方案提供参考。