Acute care surgery

Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery

The Healthcare Economics Committee of the American Association for the Surgery of Trauma has published a series of three articles on the topic of value in acute care surgery (ACS). In this series, the key elements of value, cost and outcomes, and the impact of stakeholder perspective on what constitutes high-value care are discussed. The fourth article in this series continues the discussion by focusing on the unique economic value that an ACS service brings to a hospital system and its patients. Characterized by the immediate 24-hour availability of surgeons trained in trauma management, emergency general surgery, and surgical critical care, acute care surgeons extend the benefits of surgical rescue and critical care to all hospitalized patients. As such, an ACS service acts as a vital part of a hospital's infrastructure to successfully care for complex and seriously ill patients, in addition to enabling the establishment of other, high revenue-generating services such as vascular, transplant, and complex oncologic surgery programs. The trauma service acts as intake for patients that lead to downstream revenue creation by other disciplines such as orthopedic and neurological surgery, while trauma center designation itself results in dedicated state funding to ensure trauma readiness in many states in the United States. The traditional "value equation" in health care of outcomes achieved per dollar spent is ill-suited to capture many of these unique aspects and benefits of ACS. This article provides the background to understand the economic value of an ACS service and future directions toward improving overall value of care.

Acute care surgery (ACS) is a specialty that includes trauma, emergency general surgery, and surgical critical care. It has become a vital surgical specialty in the United States, providing surgical services, rescue functions, disaster response, and other important services. Despite its key role in patient care and hospital operations, ACS faces challenges to its sustainability. This overview targets readers who wish to understand the structure and scope of ACS and who work with or manage these practices. The goal is to provide an overview of ACS, its current challenges, and suggestions for developing the specialty. This consensus statement was created by the Acute Care Surgery Workforce Workgroup, which includes representatives from various national surgical organizations. The article combines current ACS models, staffing and compensation practices, and institutional value. It relies on expert agreements and national trends. Several key themes are examined. The value of ACS is shown through better patient outcomes, efficiency, cost savings, and support for institutional missions like disaster preparedness and education. Current ACS programs differ significantly in structure, but two main staffing models exist: traditional (historic) and time delineated. Each model has its own advantages and challenges regarding workload, sustainability, and academic involvement. Regardless of the staffing model, most physician compensation often depends on the measurement of work relative value units. However, these do not fully capture the extent and intensity of ACS work. Additional challenges for the specialty include inconsistencies in terminologies, the absence of board certification, and varying compensation standards. Acute care surgery is a crucial specialty that provides significant value to patients, hospitals, and health care systems. To maintain sustainability and quality, health care leaders need to consider the complexities of ACS practice discussed in this article as well as local demands. Staffing and compensation models should be sustainable and optimize for patient care. Recognizing both clinical and nonclinical contributions of ACS surgeons is essential for resilience and further development of the specialty.

Acute-care surgery (ACS), trauma, and surgical critical care (SCC) fellowships graduate fellows deemed qualified to perform complex cases immediately upon graduation. We hypothesize international fellow rotations can be a resource to supplement operative case exposure. A survey was sent to all program directors (PDs) of ACS and SCC fellowships via e-mail. Data were captured and analyzed using the REDCap (Research Electronic Data Capture) tool. The survey was sent to 113 PDs, with a response rate of 42%. Most fellows performed less than 150 operative cases (59.5%). The majority of PDs thought the operative exposure either could be improved or was not enough to ensure expertise in trauma and emergent general surgery. Only a minority of the PDs found their case load exceptional (can be improved: 43%, not enough: 30% exceptional: 27%). Most PDs thought an international experience could supplement the breadth of cases, provide research opportunities, and improve understanding of trauma systems (70%). Ten sites offered international rotations (70%). Most fellowships would be willing to provide reciprocity to the host institution (90%). The majority of PDs for ACS, trauma, and SCC programs perceive a need for increased quality and quantity of operative cases. The majority recognize international fellow rotations as a valuable tool to supplement fellows' education.

Acute care surgery encompasses trauma, surgical critical care, and emergency general surgery (EGS). While the first two components are well defined, the scope of EGS practice remains unclear. This article describes the work of the American Association for the Surgery of Trauma to define EGS. A total of 621 unique International Classification of Diseases-9th Rev. (ICD-9) diagnosis codes were identified using billing data (calendar year 2011) from seven large academic medical centers that practice EGS. A modified Delphi methodology was used by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes to review these codes and achieve consensus on the definition of primary EGS diagnosis codes. National Inpatient Sample data from 2009 were used to develop a national estimate of EGS burden of disease. Several unique ICD-9 codes were identified as primary EGS diagnoses. These encompass a wide spectrum of general surgery practice, including upper and lower gastrointestinal tract, hepatobiliary and pancreatic disease, soft tissue infections, and hernias. National Inpatient Sample estimates revealed over 4 million inpatient encounters nationally in 2009 for EGS diseases. This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.

Acute care surgery (ACS) model of care delivery has many benefits. However, since the ACS surgeon has limited control over the volume, timing, and complexity of cases, traditional metrics of operating room (OR) efficiency almost always measure ACS service as "inefficient." The current study examines an alternative method-performance fronts-of evaluating changes in efficiency and tests the following hypotheses: (1) in an institution with a robust ACS service, performance front methodology is superior to traditional metrics in evaluating OR throughput/efficiency, and (2) introduction of an ACS service with block time allocation will improve OR throughput/efficiency. Operating room metrics 1-year pre-ACS implementation and post-ACS implementation were collected. Overall OR efficiency was calculated by mean case volumes for the entire OR and ACS and general surgery (GS) services individually. Detailed analysis of these two specific services was performed by gathering median monthly minutes-in block, out of block, after hours, and opportunity unused. The two services were examined using a traditional measure of efficiency and the "fronts" method. Services were compared with each other and also pre-ACS implementation and post-ACS implementation. Overall OR case volumes increased by 5% (999 ± 50 to 1,043 ± 46: p < 0.05) with almost all of the increase coming through ACS (27 ± 4 to 68 ± 16: p < 0.05). By traditional metrics, ACS had significantly worse median efficiency versus GS in both periods: pre (0.67 [0.66-0.71] vs. 0.80 [0.78-0.81]) and post (0.75 [0.53-0.77] vs. 0.83 [0.84-0.85]) (p < 0.05). As compared with the pre, GS efficiency improved significantly in post (p < 0.05), but ACS efficiency remained unchanged (p > 0.05). The alternative fronts chart demonstrated the more accurate picture with improved efficiency observed for GS, ACS, and combined. In an institution with a busy ACS service, the alternative fronts methodology offers a more accurate evaluation of OR efficiency. The provision of an OR for the ACS service improves overall throughput/efficiency.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Acute Care Surgery is a discipline that includes trauma care, surgical critical care, and emergency surgery. It is organized in different models and provides mainly operative and nonoperative care. The aim of this study was to provide a demographic analysis of the care of surgical patients at the Emergency Department (ED) in a large teaching hospital in Shanghai, where general surgeons and orthopedic surgeons take care for most of all acute surgery. A bilingual questionnaire was developed to collect data for patients referred to the general or orthopedic surgeon in the ED (June–September 2008). Data about the gender, age, diagnosis, diagnostic tools, treatments, and outcomes were collected. A total of 255 questionnaires were collected; the most common diagnoses of patients were infections of abdominal organs and fractures. Complementary diagnostics like X-ray (59%), blood tests (36%), and ultrasound (17%) were frequently used. More than half of the patients were discharged afterwards most of them with followup. This study gives a first overview of acute care surgery of the emergency patients of the ED in a large Chinese metropolitan hospital.

The impact of an acute care surgery model on general surgery service productivity

Robotic-assisted surgery is increasingly used in acute care surgery, but the impact of individual surgeon robotic case volume on outcomes for both elective and emergency general surgery procedures remains uncertain. To evaluate the association between annual surgeon robotic case volume and patient outcomes following robotic-assisted elective and emergency general surgery. This retrospective cohort study used data from the Premier Healthcare Database (PHD), a large US all-payer hospital database, from January 2021 to December 2023. The PHD aggregates data from nonprofit, community, and teaching hospitals across rural and urban areas, representing 25% of all US inpatient admissions. Adult patients (aged ≥18 years) undergoing robotic-assisted cholecystectomy, colectomy, appendectomy, small bowel resection, or ventral hernia repair were included. Annual surgeon-level robotic case volume, categorized as low (≤25), intermediate (26-75), high (76-150), or very high (≥151). The primary outcome was conversion to open surgery; secondary outcomes included postoperative complications, intensive care unit (ICU) admission, 30-day readmission, operative time, hospital length of stay, total hospital cost, and in-hospital mortality. Multivariable logistic and linear regression models, respectively, were used to estimate adjusted odds ratios (AORs) and mean ratios with 95% CIs. Models adjusted for patient demographics, hospital characteristics, and surgeon specialty. Among 185 924 patients undergoing robotic procedures (137 879 elective and 48 045 emergency), most (58.2%) were female (57.1% of elective and 61.5% of emergency cases). Mean (SD) patient age was 54.9 (16.6) years overall (55.6 [15.8] years for elective and 53.0 [18.5] years for emergency procedures). In elective procedures, increasing annual surgeon volume was associated with stepwise improvements across most outcomes; compared with low volume surgeons, very high volume surgeons had lower odds of conversion to open surgery (AOR, 0.45; 95% CI, 0.36-0.56), complications (AOR, 0.87; 95% CI, 0.79-0.96), readmission (AOR, 0.79; 95% CI, 0.68-0.91), and ICU admission (AOR, 0.61; 95% CI, 0.46-0.82). Operative time (mean ratio, 0.77; 95% CI, 0.75-0.79), hospital length of stay (mean ratio, 0.89; 95% CI, 0.88-0.91), and costs (mean ratio, 0.83; 95% CI, 0.82-0.84) were also significantly lower. In emergency procedures, very high vs low surgeon volume was associated with lower odds of conversion to open surgery (AOR, 0.73; 95% CI, 0.54-1.00) and modest reductions in operative time (mean ratio, 0.88; 95% CI, 0.85-0.91) and cost (mean ratio, 0.92; 95% CI, 0.89-0.94). No association was observed between surgeon volume and in-hospital mortality in either cohort. In this cohort study, greater annual surgeon robotic case volume was associated with better patient outcomes in elective general surgery and, to a lesser degree, in emergency procedures. These findings highlight the importance of surgeon-specific experience in robotic surgery and may inform training, credentialing, and strategies for safe expansion of robotic capabilities in acute care surgery.

Most studies evaluating acute care surgery (ACS) models of care for patients with emergency general surgery (EGS) conditions have focused on patients who undergo surgery while admitted under the care of the ACS service. The purpose of this study was to prospectively examine the case-mix of admissions and consultations to an ACS service at a tertiary centre to identify the frequency and distribution of both operatively and nonoperatively managed EGS conditions. In this prospective cohort study, we evaluated consecutive patients assessed by the ACS team between July 1 and Aug. 31, 2015, at a large Canadian tertiary care centre. This included all consultations and outside hospital transfers. Diagnoses, demographic characteristics, comorbidities, intervention(s), complications, readmission and in-hospital death were captured. The ACS team was involved in the care of 359 patients, 176 (49.0%) of whom were admitted under the direct care of the ACS team. Nonoperative care was indicated in 82 patients (46.6%) admitted to the ACS service and 151 (82.5%) of those admitted to a non-ACS service (p < 0.001). Bowel obstruction (37 patients [21.0%]) was the most common reason for admission, followed by wound/abscess (24 [13.6%), biliary disease (24 [13.6%]) and appendiceal disease (23 [13.1%]). Rates of 30-day return to the emergency department and readmission were 17.0% and 9.1%, respectively, and the in-hospital mortality rate was 1.7%. Acute care surgery teams care for a wide breadth of disease, a considerable amount of which is managed nonoperatively.

Acute care surgery (ACS) was developed as a consultant led organizational framework designed to enhance the promptness and quality of emergency general surgical care. Appendectomy and cholecystectomy are considered standard ACS procedures; nevertheless, the reported rates of postoperative complications are varied, attributed to differences in patient demographics, illness severity, surgical care, and institutional policies. This meta-analysis, executed in alignment with PRISMA 2020 recommendations, assessed publications published from January 2010 to December 2025 that investigated postoperative outcomes following emergency appendectomy and cholecystectomy within the contexts of ACS or emergency general surgery. Eligible trials comprised adult or mixed-age groups with recorded perioperative outcomes. Independent reviewers did the data extraction and quality check. When it made sense, random-effects meta-analyses were done, and the I² statistic was used to measure heterogeneity. Evidence synthesis demonstrated that the application of ACS typically improves surgical speed, reduces hospital length of stay, and yields comparable or diminished postoperative complication rates in contrast to conventional on call systems. Infections at the surgical site, damage to the bile duct, bile leaks, and abscesses in the abdomen were all common problems. Comorbidity, illness severity, operating delay, and open surgical conversion were all factors that led to bad outcomes. On the other hand, early intervention and minimally intrusive methods were always linked to better results. In general, ACS-based care is a good and flexible way to handle emergency appendectomy and cholecystectomy. It follows the rules of quality, safety, and efficient use of resources. The ongoing diversity among studies highlights the necessity for defined care pathways and sustained high-quality research focused on ACS.

IntroductionGlobally every year, millions of patients sustain traumatic injuries and require acute care surgeries. A high incidence of chronic opioid use (up to 58%) has been documented in these populations...

Compartment syndrome has been defined as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space”.1 It is most commonly seen after injuries to the leg2-5 and forearm6-8 but may also occur in the arm,9 thigh,10 foot,11-13 buttock,14 hand15 and abdomen.16 It typically follows traumatic injury, but may also occur after ischaemic reperfusion injuries,17 burns,18 prolonged limb compression after drug overdose19 or poor positioning during surgery.20-24 Furthermore, subclinical compartment syndromes may explain the occurrence of a variety of postoperative disabilities which have been identified after the treatment of fractures of long bones using intramedullary nails.25 Approximately 40% of all acute compartment syndromes occur after fractures of the tibial shaft26 with an incidence in the range of 1% to 10%.26-30 A further 23% of compartment syndromes are caused by soft-tissue injuries with no fracture and fractures of the forearm account for 18%.26 Acute compartment syndrome is seen more commonly in younger patients, under 35 years of age31 and therefore leads to loss of function and long-term productivity in patients who would otherwise contribute to the country’s workforce for up to 40 years.

Acute care surgery: The safety net hospital model