LYNETTE SCHERER, M.D., chief medical officer with Surgical Affiliates Management Group Inc., has been studying how to improve emergency surgery by deploying an acute care surgery model in the non-trauma setting. Scherer was co-author of a five-year study on the issue published this year by the American College of Surgeons. It found that this model produced shorter lengths of stay, fewer complications and reduced costs. | Interview by Bob Kehoe
What led to the study?
Scherer: This model had been successful with patients in the trauma setting. We applied the model to Sutter General and Sutter Memorial hospitals in Sacramento, Calif. — this is a community hospital that had no residents, no extra staffing and no specific trauma center designation.
Part of the reason we wanted to do the study was because this had never been done before and we saw obvious potential for improvements in patient care.
We studied the results from the first year of the model and published that work, and then studied the model for the next four years and produced a follow-up paper showing that we could execute and sustain the model.
What stood out in the findings?
Scherer: One thing that was most important to us was the halo effect that trauma care is famous for providing. That is, when you bring a trauma center into a hospital, you make such improvements as shortening laboratory times, increasing availability of radiology and having surgeons available and ready to go. That halo effect extends to other areas of surgery.
What jumped out at us in this study was that the acute care surgery model provided a halo effect as well. We saw a shorter length of stay, which made sense to us because we were available and prepared to perform the operations on a more timely basis. One thing we didn’t expect was that the elective general surgery caseload would stay the same for those surgeons not participating in the model.
Elsewhere, lengths of stay decreased by 12 percent, but the number of patients who returned to the emergency department did not increase, which was a real positive. Our complications rate fell about 43 percent overall, going from 21 to 12 percent. Length of stay dropped from 3.0 to 2.3 days and hospital costs dropped by 31 percent over total case volumes, which produced about $2 million in savings a year.
What types of procedures did you analyze and why?
Scherer: We looked at all operations, but chose to break it down into appendectomies, cholecystectomies and laparotomies, because they are most commonly performed by an acute care surgery service.
How did the model work?
Scherer: We had 3.5 full-time-equivalent general surgeons with trauma critical care training who each took 24-hour, in-house shifts. The surgeons could travel between two facilities, but they were on duty, present at one of the hospitals for the full 24 hours. The surgeons were available to help with in-house emergencies and were expected to respond to the ED within 30 minutes.
In addition to the surgeon on call, we had a midlevel — either a nurse practitioner or a physician’s assistant — who rounded with the team every day. The midlevel and the surgeon would handle all new consults and admissions for the day. The next day, the new surgeon would begin with the same midlevel person, who generally worked three or four days in a row to ensure continuity.
How does this approach differ from traditional emergency surgeries?
Scherer: With a group of surgeons who are committed to providing care for emergency surgery patients in this way, we agree on how cases will be managed. This significantly reduces variability in care and repeatedly has been shown to be an efficient way to practice medicine.
A more common model for managing emergency surgery patients is that the elective surgeons in town participate in an on-call roster through the ED. In many instances, these surgeons do the emergency work in series with their elective surgeries, meaning they’ll finish their elective day and move on to the emergency work. So, sometimes emergency patients have to wait until the end of the day or until a slot opens up in the schedule.
Can you give an example of where variability was eliminated?
Scherer: A big one is antibiotic use after an appendectomy. Few things will incite more conversation among surgeons than how long to continue with antibiotics after an appendectomy. We use an evidence-based algorithm that our surgeons support, so we reduce variability, cost and complications associated with excess or inappropriate use of antibiotics. This saves money and is better for the patient.
Where did the savings occur in this project?
Scherer: The majority of the savings came from a decrease in hospital costs, which was attributable to the decreased length of stay. The costs went from about $12,000 to $8,300. But, it also was because the surgeons agreed to use the same instruments, so that inappropriate or excess instruments weren’t opened. There was also decreased waste of operative supplies.
Can this approach be replicated?
Scherer: Yes. The key is getting surgeons who are willing to participate.
What is the postsurgical handoff and care coordination like in these cases?
Scherer: That’s one of the criticisms of the model — that there is a different surgeon on every day and whether the surgeon coming on to the case the next day can possibly know everything that is going on with these complicated patients.
We have a proprietary and specific sign-out list that our midlevel practitioners prepare, document and edit every day that documents all of the critical features of the patient’s care in a checklist. We go through that checklist with every patient, and our midlevel practitioners are key to making that happen. Additionally, all of our surgeons are expected to be familiar with our practice management guidelines.
If the patient is post-op Day 1 after an appendectomy, the oncoming surgeon will understand where he or she falls in our algorithm. Understanding the algorithm helps with the handoff process. The key feature is the face-to-face meeting among the outgoing surgeon, the incoming surgeon and the midlevel who is on duty. So, there’s a real opportunity to ask questions and exchange information.
THE SCHERER FILE
Fellowship-trained trauma surgeon certified in general surgery and trauma/critical care by the American Board of Surgery. Joined Surgical Affiliates Management Group in 2013 after serving as professor of surgery and chief of trauma and emergency surgery at UC Davis Medical Center, Sacramento, Calif. While at UC Davis, assisted the Air Force in training trauma surgeons to treat soldiers on the front lines in Iraq and Afghanistan.
Serves as trauma medical director at Mercy San Juan Medical Center in Carmichael, Calif., a Level II trauma center that has continuously achieved verification from the American College of Surgeons since 2000.
“We need to broaden our approach. I think we can apply this model broadly to more complicated surgical diseases like diverticulitis and bowel obstruction.”