Acute Care Surgery - Principles and Practice

"Part IV System and Curriculum Development (p. 742-743)

Centralization 46 Development of a Regional System for Surgical Emergencies (RSSE)

A. Brent Eastman, David B. Hoyt, and J.Wayne Meredith

The Problem—The Solution

In the United States, in the ?rst decade of the twenty-?rst century, a 60-year-old man run over by a truck may have better access to life-saving care than a man with a perforated viscus or a ruptured abdominal aortic aneurysm. The reason is that many states and counties now have regional systems to coordinate the care of injured patients, but the concept of a geographic plan for nontraumatic, but devastating, surgical emergencies is new. The trauma system model is appropriate for these other surgical emergencies and possibly for certain medical emergencies as well, such as stroke and acute myocardial infarction.

The concept of trauma system development is based on the principle that the system adds value over and above the efforts of individual practitioners or hospitals.1–3 It is historical irony that today there are well-trained and quali?ed surgeons in most of the country’s community hospitals, but there are too few surgeons who are committed to providing emergency department coverage 24 hours a day. Training has improved over the past 30 years to the point that most surgeons who complete an accredited general surgery program are well quali?ed to perform most acute care operations.

Yet surgical coverage in emergency department call panels is a critical health care challenge in the United States. The problem has many compounding causes. The ?rst is a physician shortage nationwide: some experts estimate that the United States will be short some 200,000 physicians within the next decade, and a large portion of the missing physicians will be specialists in surgery.4 There is also inadequate reimbursement for providers along with soaring medical malpractice insurance costs. Furthermore, a powerful cultural change has occurred prompting many young surgeons to seek a more balanced life style.

The net effect is fewer professional hours devoted to patient care. Finally, the population is aging, with octogenarians representing the most rapidly growing segment, and the resources required for the elderly with acute severe illnesses are greater than for younger patients with the same emergencies (Table 46.1).5 All of these factors speak to the urgent need for a system designed to coordinate and ensure access to emergency surgical care. The trauma system model should be strongly considered in addressing the treatment of nontraumatic surgical emergencies (NTSEs).

Trauma systems are designed to identify injured patients in the prehospital setting, establish triage guidelines, and institute protocols of care. Furthermore, a trauma system provides for the immediate availability of a coordinated team with the resources necessary to care for critically injured patients. In regions without a trauma system, autopsy records have shown an unacceptable rate of preventable deaths (i.e., deaths of patients who would have survived with appropriate surgical intervention).

Lowered rates of preventable deaths re?ect the presence of a system that rapidly identi?es those at risk and transports them to the appropriate facility. 7,8 An analogous situation may exist for NTSEs. Figure 46.1 describes the preventable death data derived from the San Diego Trauma Registry. The San Diego Trauma Registry was inaugurated in 1984 with the resultant immediate decline in the number of preventable deaths. This dramatic change is directly attributable to the implementation of all components of a regionalized trauma system plan."