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The past decade has observed an exponential increase in the implementation of ACS services, which has provided the impetus to determine the ramifications of this newly defined specialty on important clinical outcomes. Significant improvements in time management and patient outcomes have been noted. Two studies out of Canada show promising results with regards to time making treatment decisions. Implementation of an ACS service at one institution reduced surgical decision time by 15%, presumably due to the more immediate availability of an attending surgeon, and shortened average time-to-stretcher from the waiting area for all patients in the emergency department (ED) by 20%, thereby reducing ED overcrowding.20 Another study showed shorter times to the operating room (OR) for patients (192 vs 221 minutes, p = 0.015) after creating an ACS service, and proportionally less after-hours operative cases as well (60 vs 72.6%, p <0.0001).21
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Given the common nature of appendicitis, several studies have examined ACS outcomes specific to its treatment. In one of the first published studies examining patient outcomes in an ACS practice model, patients with appendicitis treated by an ACS team compared to patients treated by a traditional general surgery on-call practice model had decreased time from consultation to the OR (3.5 vs 7.6 hours, p <0.05), decreased time from presentation to the ED to the OR (10.1 vs 14.0 hours, p <0.05), decreased rates of appendiceal rupture (12.3% vs 23.3%, p <0.05), decreased complication rates (7.7 vs 17.4%, p <0.05) and decreased hospital length of stay (LOS) (2.3 vs 3.5 days, p <0.001).22 Similar results were reported in other studies comparing ACS to traditional general surgery call, with reduction in patient time-to-surgical evaluation, shorter time to OR, shorter length of stay as well as cost savings.21,23,24,25,26,27 This was due to around-the-clock presence of the acute care surgery attending in the hospital, and cases that presented in the night hours were not delayed until the following morning as was the previous practice with the traditional on-call model.25
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The influence of an ACS service on biliary pathology (ie, cholecystectomy outcomes) has also been the focus of intense investigation, with several benefits again reported. A study previously discussed showed that the average time for a patient to receive surgical evaluation dropped by 5.84 hours, time to the OR was reduced by more than 25 hours, there were fewer complications, hospital LOS was 1.9 days shorter, and cost savings of approximately $3000 per patient were noted.23 Similar outcomes have been observed at other institutions. A 2011 study of similar design found shortened average time from ED to OR (24.6 vs 35.0 hours, p = 0.0276), decreased complication rates (7.0% vs 18.5%, p = 0.032), and decreased after-hours cases (5.6% vs 21.0%, p = 0.004).27 Decreased time to OR was also achieved by Lim et al in their 2013 article, though they did not note any significant decreases in complications, conversions to open procedures, or hospital LOS.26 Another study published recently reported that after their institution implemented an ACS service patients went to the OR 5 hours faster on average, more patients had their gallbladder removed in the first 24 hours after presentation (75% vs 59%, p = 0.004), overall hospital LOS was 1.4 days shorter, fewer complications were noted (3.9% vs 13.8%, p = 0.001), and fewer cases were converted from laparoscopic to open (4.2% vs 11.6%, p = 0.013).28
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One concern initially raised is that the combination of an emergency general surgery practice and a trauma practice would negatively impact trauma outcomes. Fortunately this concern has not been borne out in the published literature. Multiple studies have shown that despite the increase in workload that occurs with development of an ACS service, times to OR for the injured patient are not significantly affected, and morbidity/mortality rates did not increase.16,29,30
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An addition concern is that the practice of general surgeons not part of the ACS group would be affected by reduced productivity. It is intuitive that trauma and acute care surgeons participating in the ACS service would experience increased operative case volume, and surveyed ACS surgeons have shown increased job satisfaction as a result.31 The effects on non-ACS general surgeons have been examined. One study showed that, somewhat surprisingly, wRVU production improved in both ACS and nontrauma general surgeons (44%, 3%) after establishment of an ACS service. Increases in wRVU production for the nontrauma general surgeons were surmised to be a result of fewer interruptions to, and maximal usage of, elective surgery time. Job satisfaction increased for surgeons in both groups of this study.32 Another group found that although their trauma/ACS surgeon wRVU production increased by 140% after integration of emergency general surgery, the nontrauma “elective” general surgeons’ wRVU production fell by 8%.33 This was counterbalanced somewhat by overall increased billing collections in both groups (129% in ACS group, 7% in general surgery group), resulting in an annual departmental revenue boost in excess of $2 million. General surgeons in the nontrauma group in this study were able to increase their elective caseload by 23%.33
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Finally, implementing an ACS service at a nontrauma hospital has also been examined. Beneficial effects were again observed, with fewer complications, shorter hospital LOS, and monetary savings again noted. After formation of an ACS service, appendectomy complications fell from 13% to 3.7% of cases (p <0.0001), and length of hospital stay decreased from 3.0 to 2.3 days (p <0.0001). Cholecystectomy patients experienced fewer complications as well (9% vs 21%, p = 0.012), and also were noted to have shorter length of stay (3.8 vs 5.3 days, p = 0.0004).34 This study highlights the flexibility and variation of ACS groups between different practice locations and settings. Acute care surgery can encompass trauma surgery, elective and emergent general surgery, and surgical critical care, but it is not bound to include all of these areas in every instance.