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

Abstract

BACKGROUND The Acute Care Surgery (ACS) model has been widely adopted by hospitals across the United States, with ACS services managing emergency general surgery (EGS) patients previously treated by general surgery (GS) services. We evaluated the operational and financial impact of an ACS service model on general surgeons at an academic medical center. METHODS Using WiseOR® (Palo Alto, CA), we compared surgical case volumes for the GS service two years before (October, 2013 - September, 2015) and two years after (October, 2015 - September, 2017) implementation of an ACS service at the University of Vermont Medical Center. From financial reports, we obtained monthly wRVUs, clinical FTEs, net patient revenue, and payer mix for the GS service and compared the two years before and after ACS model implementation. RESULTS There was a significant reduction in the average number of cases performed by the GS service following ACS service implementation (monthly mean ± SD, 139.1 ± 16.0 vs. 116.7 ± 14.0, p < 0.001). The normal-hours caseload remained stable, while a significant decrease in after-hours cases accounted for the reduction in overall volume. Despite the reduction in operative volume, the decrease in mean monthly wRVU/FTE for the GS service when comparing the pre- and post- ACS periods did not reach statistical significance (614.9 ± 82.9 vs. 576.3 ± 62.1, p = 0.08). There was a significant increase in average monthly clinic-derived wRVU/FTE for the GS service (106.3 ± 13.5 vs. 120.5 ± 16.4, p = 0.007). CONCLUSIONS Shifting EGS patient management from the GS to ACS service did not negatively impact the productivity of the GS service. Background

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“…19 While ACS service implementation has been shown to improve the lag time to operation, decrease LOS, and improve complication rates, the effects on hospital finances and cost effectiveness are less clear. 5,[20][21][22] For trauma centers and safety net institutions with heavily unfunded populations, maintenance of trauma services, elective services, and EGS services may be a strain on financial resources. 23 For our institution, this led to the creation of the hybrid TACS Service.…”

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“…Numerous studies have demonstrated a multitude of benefits from the ACS model in terms of clinical outcomes, costs, and higher satisfaction of both ACS and GS surgeons. [2][3][4][5][6][7][8][9][10][11][12] In contrast to the traditional surgical service, the majority of operative cases on the ACS service are nonelective-a small proportion being immediately life threatening-with the large proportion being semielective, where the surgery should be performed early, usually within 24 hours, for optimal outcomes. Hence, for an effective ACS service, the ready availability of a staffed OR and 24/7 availability of a trained surgeon are paramount.…”

“…Over the past two decades, trauma surgeons have incorporated EGS in their scope of practice developing a new paradigm of care and the development of the new surgical discipline of ACS. Numerous studies have demonstrated a multitude of benefits from the ACS model in terms of clinical outcomes, costs, and higher satisfaction of both ACS and GS surgeons 2–12 . In contrast to the traditional surgical service, the majority of operative cases on the ACS service are nonelective—a small proportion being immediately life threatening—with the large proportion being semielective, where the surgery should be performed early , usually within 24 hours, for optimal outcomes.…”

“…1 This transformation to an ACS model of care delivery has been beneficial on multiple fronts: integration of patient care, improvements in clinical outcomes, decreases in lengths of stay, and increased job satisfaction for both ACS and non-ACS surgeons by stabilizing clinical volumes and reducing after-hours workload, respectively. [2][3][4][5][6][7][8][9][10][11][12] An effective ACS model requires availability of a competent ACS surgeon to perform EGS surgeries at short notice and a staffed operating room (OR) for EGS surgeries to be performed in a timely manner. With the evolution of ACS from trauma surgery, surgeon availability is rarely an issue.…”

“…This transition has led to a rebranding of trauma surgeons as acute care surgeons and the creation of a new surgical specialty, acute care surgery (ACS), encompassing trauma, surgical critical care (SCC), and EGS 1 . This transformation to an ACS model of care delivery has been beneficial on multiple fronts: integration of patient care, improvements in clinical outcomes, decreases in lengths of stay, and increased job satisfaction for both ACS and non-ACS surgeons by stabilizing clinical volumes and reducing after-hours workload, respectively 2–12 …”