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A typical week of general surgery emergency call embodies the busiest surgical service in Canada. General surgeons respond to emergencies around the clock and provide sustained care through all phases of critical illness, multiorgan failure, recovery and rehabilitation. Unfortunately, the framework to support acute general surgery has not kept pace with the high levels of acuity and complexity while meeting clinical imperatives of prompt care and attention to detail. In this issue of the Canadian Journal of Surgery, several articles outline a growing attraction to a new model of general surgery emergency care called acute care surgery (ACS).1–3 This model has been initiated in 13 Canadian centres, and there is a sweeping movement in North America to formalize such service.4
Acute care surgery provides many opportunities to improve access to care, elevate the standards of emergency care delivery and improve outcomes for patients, surgical education and general surgeons’ lifestyles. Patients with the most responsible diagnoses of appendicitis, obstruction, gallstone complications, diverticulitis, gastrointestinal malignancy, gastrointestinal hemorrhage, perforated viscus and mesenteric ischemia can be assessed more rapidly by dedicated ACS teams. Practice audits have shown reduced emergency department response time and more rapid patient access to the emergency operating room. There is also an opportunity to consolidate care so that performance improvement standards can be implemented. Whereas some data are emerging that patient outcomes are improved (reduced length of stay), a systematic approach to quality improvement needs to be undertaken to the extent that has been done in other programs such as the National Surgical Quality Improvement Project or the model of accredited trauma care. For centres that maintain rigorous surgical education programs (including those that have distributed education programs), the opportunity to improve learning experiences is enhanced.2
To be sustainable and successful, ACS exacts firm commitments from general surgeons, trainees, health professionals and institutions. The question should be posed as to whether all subspecialty general surgeons can a carry commitment and comfort zone for the spectrum of the conditions defined by ACS. Their commitment becomes strained unless they can be released from multiple competing priorities for call for other services such as trauma, hepatobiliary, transplantation and oncology disciplines. In academic centres, competing administrative and academic priorities must be reconciled with the ability to cover ACS commitments in a timely way.
Major commitment surrounds the need for careful handover of complex cases between surgeons and resident trainees and between work shifts. Handover of continuous care has become a standard in some models (e.g., in the intensive care unit); however, communication standards must be high to sustain good patient outcomes. Acute care surgery services must take a systematic approach to minimize handover issues through the audit of care practices and the creation of daily standard handover pathways between surgical teams.
It is important for a centre to be committed to an innovative practice model in order to build the dynamic teams needed for ACS. In addition to staff surgeons and their trainees, such teams include advanced nurse practitioners, dietitians, physiotherapists and pharmacists. Moreover, ACS can help our colleagues who manage trauma services where operative management has dwindled. In this latter group, an innovative commitment to ACS may help us to recruit and retain key surgeons who can maintain surgical skills.
Finally, there must be a commitment to financial stability. The unpredictable pace of emergency surgery must be reconciled with the needs for general surgeons and teams to maintain their availabilities without being distracted by competing clinical, administrative or academic priorities. A stable funding model combined with a commitment for protected operating room time throughout the week must be supported by the institution. Such commitment by perioperative services also avoids the conundrum of performing important and technically demanding surgery at night when staff support is reduced.
Is the ACS model relevant to hospitals that serve communities outside major tertiary or quarternary centres? The answer to this will be related to access to a critical mass of staff surgeons and the financial stability of the centres. Because many centres now participate as regional academic campuses with postgraduate and undergraduate learners, there is a compelling argument to support this model in such sites. Moreover, a regional or provincial referral system that defines “life and limb” threatening general surgery conditions may facilitate rapid network transfers to the centre that is best equipped and staffed.
In summary, we are observing a dynamic growth of interest in ACS, which is replacing the outdated framework for definitive and life-saving care of the sickest general surgery patients. This will create an unprecedented opportunity to advance patient care, surgical education and research and define a new unifying force in Canadian general surgery.
Competing interests: None declared.