Surgicalists: A Model to Address Acute-Care Shortages in EDs

Having surgicalists on staff could benefit hospitals as value-based reimbursement becomes the industry standard. A dedicated team can help improve key metrics.

Watch any television show about health care, and you’ll see a reassuring sight: A patient requiring immediate surgery is rushed to the emergency department, where dedicated surgeons with scalpels at the ready spring into action to save the patient.

It makes for a compelling image, but it’s not what happens daily in thousands of EDs across the nation.

In reality, when patients need them most, surgeons might not be available. According to a Robert Wood Johnson Foundation study,1 three-quarters of America’s EDs don’t have enough on-call surgeons to meet the demand for daily, around-the-clock specialty care. The Centers for Disease Control and Prevention reports that almost 10 million Americans are in a surgical desert, without access to the emergency surgical care they need..2 The Massachusetts Medical Society estimates a national shortage of 46,100 surgeons by 2020.3 This shortage comes at a time when demand for emergency surgery is high and patient volume in the ED is increasing: About 3 million Americans are admitted to hospitals for emergency general surgery each year.4

The lack of readily available, qualified surgeons for emergency cases can have repercussions, including ED overcrowding, more patients leaving without being seen, increased patient dissatisfaction and decreased quality-of-care measures. These metrics are detrimental to a hospital’s standing in a value-based payment system and on the quality of care delivered to its community.

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The shortage of emergency surgeons reflects a shortage of surgeons overall. Reasons for this shortage include:

• Reluctance. Many doctors, including surgeons, believe the high volume of uninsured and underinsured patients in the emergency department result in lower reimbursements.

• Growth. More surgeons today are specialists, uninterested in being on-call. That also results in diminished experience and skills in treating emergency acute care surgery patients.

• Balance. Managing their professional and personal lives is a growing concern for many doctors, especially surgeons. Being on-call not only interferes with their personal lives, but it commonly affects their elective cases and office practices, impacting revenue. The result? Many general surgeons consider on-call coverage a nuisance.5 Surgeons with elective practices are less willing to take night and weekend call. Surgeons with mature practices or nearing retirement don’t want the hassle.

Effects on Delivery

The acute-care surgery shortage has an impact on the delivery of value-based health care in several ways. Three of the most significant:

• Quality consequences. The fragmented nature of the traditional on-call system doesn't lend itself to continuity of care and the standardization of best practices recognized as drivers of quality care. An article in Modern Healthcare restates what many physician leaders know: Today’s patients with emergency surgery needs often are sicker than patients in the past..6 If care is delayed, patients are more likely to suffer from complications and require longer hospital stays. As quality metrics go down, so does value-based reimbursement.

• Lack of leadership. To meet surgical needs in their EDs, hospitals often hire locum tenens — temporary surgeons — who cost as much as twice that of hospital-affiliated surgeons. They might not understand a hospital’s quality initiatives or have the dedication to meet the needs of a hospital where they have no community ties. Surgeons focused on their elective practices might lack similar commitment. Without dedicated, stable surgical leadership, hospitals are missing a reliable partner in the pursuit of improved care, efficiency and patient safety.

• Lower patient satisfaction. Delays, fragmented care coordination and disjointed communication all feed into decreased patient satisfaction. Lower patient-satisfaction ratings influence reimbursement negatively.

As value-based payment becomes the norm in health care, the pressures for performance will increase. Hospitals must manage acute-care surgery to produce consistently superior outcomes, avoid unnecessary readmissions and generate quality patient care. If hospitals cannot do that, the goal of value-based care — lower costs, better outcomes — is simply unattainable.

Solutions

Attempts to improve the consistency and cost-effectiveness of acute-care surgery have been made. One of the first was the surgical group with an elective practice that contracted for evening and weekend call. The attraction for the surgical groups was the capture of more patients and revenue. For a hospital, the benefit was using a surgical group that had a relationship with the facility and was willing to take on consistent responsibility for the ED.

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Sometimes these arrangements work well, but often there are drawbacks. Sharing the on-call responsibility among a few doctors with busy elective practices can be burdensome, leaving the hospital to face the consequences of surgeon burnout. The hospital also lacks the surgical leadership to focus on quality-of-care initiatives.

Recognizing the increasing need for trauma and emergency surgical coverage, the American Association for the Surgery of Trauma in 2008 established the Acute Care Surgery Fellowship to train surgeons. There are 21 fully accredited AAST Acute Care Surgery Fellowship programs . This emerging specialty equips surgeons to assume the role of acute-care surgeons. Also known as surgicalists — surgeons who practice only in the hospital — they meet the challenge of obtaining focused, coordinated

and consistent care for emergency surgical needs, by being available round-the-clock and organized into teams with a shared commitment to best practices.

These changes are producing hospital-physician alignment. Research published in the Journal of the American College of Surgeons suggests these programs can achieve improved performance metrics throughout the hospital, sustained over a five-year period.7 These include an appropriate increase in case mix index, decreased length of stay, stable or declining 30-day readmission rates, reduced complications and decreased hospital costs.

For hospitals, this approach is more than a solution to the on-call dilemma. Improved performance in quality of care, consistency, efficiency and communication yields better outcomes at lower costs, meeting the twin goals behind the pay-for-performance initiatives.

For local surgeons, this approach gives them the freedom to focus on their elective practices without on-call demands. Research indicates that patient volume for local private-practice surgeons stays the same, or increases, when a surgicalist program is established.

Surgicalists in Action

Mercy San Juan Medical Center, in Carmichael, California, is home to one of the nation’s first surgicalist programs. In 1999, it opened a trauma center that has proven to be a driver of success for the organization.

Over time, its payer mix of patients has improved, as well as its ability to get out-of-network and capitated patients repatriated to their “home” systems when their conditions stabilize. The trauma center also has contributed to the creation of an environment that allows for open, honest peer review with a commitment to closing loops and changing behavior. Mercy San Juan also launched another innovation in surgical care: applying the same rigorous standards required in trauma care for consistent best practices to the care of patients with acute surgical needs.

RELATED: Simultaneous Surgeries: Both Sides of the Debate Double Down

The model modifies trauma care standards — such as board-certified surgeons, an interdisciplinary approach, team cohesion, specific and measured responsiveness, a standardized approach to care by all providers, and peer review of all cases to identify performance improvement opportunities — into an acute-care surgery model.

In addition, when surgicalists and the hospital work as a systemwide team, numerous enhancements to quality of care and efficiency can be implemented, such as:

• Equipment reserved for critically ill or injured patients, decreasing turnaround time in diagnosis and care.

• Improvements in ED efficiencies, including reduced length of stay and faster ICU admission.

• Enhancements such as massive transfusion protocols.

• An immediately available surgical care team if routine procedures (such as childbirth) go awry.

• Institution of similar approaches to care and measurement of optimal timelines for cardiac, neurological and trauma care, such as implementing alerts and a team-based approach to immediate workup and interventions.

• Adoption of antibiotic treatment algorithms for common diseases, such as appendicitis and trauma laparotomy, to reduce variability among caregivers.

With the availability of a 24/7 surgicalist team, hospitals see not only reduced length of stay and fewer complications, but also new efficiencies across multiple departments.

The challenge of finding and retaining qualified surgeons for emergency needs is going to be a recurring issue in the coming years. The solution lies in a programmatic approach to acute-care surgery that satisfies the needs of the hospital for optimum performance while meeting the surgeon’s desire for a livable schedule, a rewarding professional challenge and attractive compensation. This approach can deliver the improved patient care metrics and efficiencies mandatory in a value-based payment world.

Leon J. Owens, MD, FACS__, is founder and chairman of the board of California-based Surgical Affiliates Management Group, which provides surgicalists to hospitals.

REFERENCES

1. Robert Wood Johnson Foundation, 2010. The Shortage of On-Call Surgical Specialist Coverage. https://www.rwjf.org/en/library/research/2010/12/the-shortage-of-on-call-surgical-specialist-coverage.html .

2. Centers for Disease Control and Prevention, FastStats Homepage, 2017. cdc.gov/nchs/fastats/emergency-department.htm .

3. NEJM CareerCenter. Physician shortages in the specialties taking a toll New England Journal of Medicine, 2011. https://www.nejmcareercenter.org/article/physician-shortages-in-the-specialties-taking-a-toll/ .

4. Scott J, Olufajo O, Brat G. Use of national burden to define operative emergency general surgery. JAMA Surgery, 2016. https://jamanetwork.com/journals/jamasurgery/article-abstract/2516780 .

5. Gesenway D. Surgicalists: Why aren’t they in your hospital? Today’s Hospitalist, January 2015. https://www.todayshospitalist.com/Surgicalists-Why-arent-they-in-your-hospital/ .

6. Kutscher B. Outpatient care takes the inside track. Modern Healthcare, August 2012. https://www.modernhealthcare.com/article/20120804/MAGAZINE/308049929/outpatient-care-takes-the-inside-track .

7. O’Mara MS, Scherer L, Wisner D, Owens LJ. Sustainability and success of the acute care surgery model in the nontrauma setting. Journal of the American College of Surgeons, November 2013. https://www.journalacs.org/article/S1072-7515(14)00220-8/abstract .