Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.
Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.
Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.
EMERGENCE OF ACUTE CARE SURGERY
Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels . From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion . This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity . The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” . Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity . Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 . An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages . As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 .
At the center of these issues, described as “the perfect storm,” is the patient . Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm . In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery . This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.