By Lynette Scherer, MD, FACS
The problems are all too familiar: a struggle to deliver timely care, acceptable lengths of stay, cost-effective services, reduced complications and readmissions, and much more. It’s no exaggeration that emergency and acute surgical care in many hospitals are in dire need of life support.
Most importantly, these problems dramatically impact patients’ quality of care and outcomes. With the growth of pay-for-performance reimbursements tied to quality measures, hospital profits also suffer—costing facilities money that could be effectively channeled into expanded patient services and growth.
Many of today’s difficulties stem from the rapidly changing face of healthcare. In part, they result from the remixing and rebalancing of surgical subspecialties. The once omnipresent general surgeon with a broad skill set and diverse patient experience is all but extinct. Additionally, true trauma surgeons are hard to find. Compounding the problem, modern surgeons are seeking a better work-life balance and shunning the added income of on-call hospital shifts in favor of a more predictable and manageable schedule.
Yet most hospitals continue to staff their emergency services with community-based general surgery groups or individual surgeons who are committed to their elective practices first. Without a cohesive emergency surgical team in place, standardization of care and hospitalwide care coordination is a major challenge. This significantly compromises compliance with standard practice guidelines and quality measures as well as related reimbursements.
Clearly, hospitals must adapt.
As a result, a new care model is emerging to answer these challenges. It relies on highly trained surgeons to deliver dedicated on-site 24/7/365 coverage for acute care and trauma surgical patients. Perhaps most easily understood as surgical hospitalists, these physicians are in fact becoming so important that they have been recognized as a distinct medical specialty—surgicalists.
This article examines the obstacles facing high-quality, efficient, affordable emergency surgical care as implemented in most hospitals today and how a surgicalist model can significantly address these barriers to success.
Relying on community surgeons to serve emergency patients creates clear conflicts of time and priorities because those surgeons are committed to their own elective practices. When summoned from off-site, surgeons cannot always respond in a timely fashion, especially during the middle of the night. Treatment for patients not deemed in true immediate need may be delayed for hours, and often on-call surgeons can refuse transfer patients at their own discretion.
The result is long patient waits and overcrowded emergency departments (ED). Some patients may simply be turned away, while others leave of their own volition. Opportunities to take in transfer cases are missed. Patient satisfaction is low, and hospital reputation dips. Most important in the ED where minutes often count, quality of care suffers—from increased surgical complications and lengths of stay to poorer outcomes.
Supply and demand
The impact of the current surgeon supply-and-demand crisis cannot be overstated. In most geographic areas, the shortage of community surgeons willing to commit to on-call ED coverage takes its toll. Many of today’s surgeons prefer to expend their energies building up elective practices and to forgo the stress and dissatisfaction of serving emergency patients at all hours of the day and night with no control over their schedules.
Also, as healthcare adapts to changing times, the surgical subspecialty mix is being redefined. The general surgeon experienced in a wide range of emergency procedures is rapidly disappearing—and with that the physician skill set needed for high-quality, versatile, efficient emergency patient care. Increasingly surgery is becoming a specialty of subspecialists. For example, today surgeons are exclusively focused on breast, colorectal, or abdominal procedures, with lucrative practices, and they have little time for and experience with the mix of patients who present in the ED. Moreover, because of the extreme demands of round-the-clock care for patients who may be clinging to life, trauma surgeons are a disappearing breed.
Compounding the difficulty is that specialized surgeons who are in fact needed in a high-level trauma center, such as orthopedics and neurosurgeons, are less likely to take time off from their busy specialized practices to cover erratic emergency shifts.
A severely short-staffed or inappropriately experienced emergency surgical team can be a recipe for disaster.
Confusion, even chaos, provides the backdrop for admission to this surgical workflow. Despite its intention, the Affordable Care Act (ACA) has drawn more patients into the ED because so few physicians accept ACA Medicaid patients, while the uninsured continue to rely on the ED for routine care. The result typically is an overflowing waiting room.
Lack of leadership
Amidst all this, there is no central management of the on-call surgeons providing care. Simply put, without leadership, cohesive surgical teams, shared direction, standardized practices, and teamwork are absent.
Lack of standardized care
Lack of leadership leads to lack of standardized care through failure to develop departmental evidence-based surgical protocols and best-practice guidelines. Individualized surgeons move ahead with their preferred practice patterns, equipment choice, and workflow, making care quality and other group initiatives impossible. This has implications for patient safety, readmissions, cost containment, and much more.
Communications and care coordination
As patients move throughout the hospital, standardized handoff protocols are essential to ensure good care coordination. For example, the nature, completeness, and consistency of clinical information provided to new caregivers, as well as the format of orders for follow-up care, heavily affect care quality and outcomes. This is especially important when surgeons are based in the community, as these surgeons are unavailable to play an ongoing role in the patient hospital journey and are not on-site to clarify information, answer questions, or revise treatment plans.
Enter the surgicalist
An acute care and trauma surgicalist program is the modern answer to today’s challenging and ever-changing hospital environment. Surgicalists—perhaps more easily understood as surgical hospitalists—provide 24/7/365 coverage of ED and inpatient surgical needs.
These talented and specially trained surgeons work exclusively in the hospital environment full-time without the distraction of an elective surgery practice. As such, they are part of a patient’s ongoing care team and help consult and manage the patient from admission through discharge—and even provide convalescent care through an on-site follow-up clinic.
An on-site medical director is an important part of a surgicalist program; this person manages the initiative, promotes quality care, and integrates the program into the hospital’s existing infrastructure. Often programs also deliver a care team that includes specialized nurses, nurse practitioners, and physician assistants, who especially help as patients enter other care areas. Surgicalist programs enable surgeons to focus on patient care and allow administrators to concentrate on more global hospital issues.
Typically, surgicalist programs are managed by outsourced providers who are skilled at recruiting and managing surgical talent dedicated to following the emerging surgicalist career path.
Overcoming key obstacles
Surgicalist programs overcome many of the traditional supply-and-demand barriers associated with on-call physicians because surgicalists can enjoy the challenge and rewards of emergency surgery with a more balanced lifestyle than available in the past. While some are general surgeons, others may be trained in the emerging specialty of acute care, which combines surgery for traumatic injuries and conditions such as appendicitis and cholecystitis. This specialty is beginning to attract a growing number of physicians for its more manageable work-life balance along with the opportunity to manage and care for challenging patient conditions. Under the surgicalist model, existing on-call surgeons with elective practices can also continue to cover shifts with more manageable schedules, assisted by board-certified full-time surgeons and other healthcare professionals.
With a reliable pool of trained surgeons covering emergency surgical cases, gone are the problems of ED surgical coverage and their consequences of long wait times, patient ED “walks,” and patient dissatisfaction. In the ED, where seconds often count, faster care means better care. Thus, performance improvements are far-reaching, from fewer complications and readmissions to overall outcomes.
Emergency surgery quality management
The on-site medical director, backed by the expertise of the surgicalist provider, plays a crucial role in ensuring that the program effects changes both in the department and hospitalwide. Best-practice care standardization as well as continuous quality, efficiency, and cost improvement initiatives can be implemented with assurance of surgeon compliance. Quality measures improve, and with greater efficiencies and shorter lengths of stay, hospitals may even have more open beds to take on a greater number of patients.
With the guidance of an experienced surgicalist firm, hospitals can step up the effectiveness of these programs by establishing benchmarks and realistic targets to meaningfully drive progress.
Hospitalwide communication and care coordination
With standardized processes and procedures, care is improved as the patient moves through the hospital. Department handoffs benefit because patient information and care plans follow a standardized format, while surgicalists and other emergency surgery team members remain on-site to coordinate care and manage communications with other hospital departments and families. Additionally, surgical leadership is in place to drive teamwork, meaningfully represent the department in the hospital, and collaborate with other departments.
Evidence-based quality improvements
The benefits of surgicalist programs are backed by a growing number of studies. A paper by O’Mara et al. (2014) documents how a tertiary referral community hospital made sustainable improvements by implementing a surgicalist program, resulting in better timeliness of care, reduced complications and lengths of stay, and lower costs.
But any healthcare practitioner who has ever walked through an overflowing ED at 2 a.m. knows the problems of traditional care models firsthand and can easily imagine the difference that expanded surgical staffing, comprehensive department- and hospitalwide organization, and greater care coordination will make.
Lynette Scherer, MD, FACS, is CEO of SAMGI (Surgical Affiliates Management Group, Inc.), the industry-leading provider of comprehensive surgicalist programs. For 25 years, the company has provided highly trained, board-certified surgeons to hospitals for 24/7/365 on-site trauma and acute care surgery coverage, optimizing performance, efficiency, and revenues.
O’Mara, M. S., Scherer, L., Wisner, D., & Owens, L. J. (2014). Sustainability and success of the acute care surgery model in the nontrauma setting. Journal of the American College of Surgeons, 219(1), 90–98. https://doi.org/10.1016/j.jamcollsurg.2014.02.022