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The Acute Care Service - A Team Approach

The Divisions of General Surgery at Sunnybook and St. Michael's Hospital have introduced a new organization for the provision of emergency services called "The Acute Care Service" (ACS). It is appropriate that we look closely at this development as it marks a change in our pattern of patient care. In the past a patient was admitted to hospital and cared for by one particular surgeon who looked after the patient for the whole hospitalization and often frequently for re-hospitalizations. The Acute Care Service replaces the single surgeon model with the provision of care by a team. This type of care has been ongoing for some time in the Department of Medicine but I believe this is the first time it has been done within the Department of Surgery here at the University of Toronto.

Robert Mustard
Robert Mustard

The Acute Care Service consists of a rotating staff surgeon, a senior resident - typically a PGY III, and one or two junior residents along with one or two clinical clerks. The staff surgeon usually changes every week and the senior resident every two to three months. The ACS is responsible for all consultations from the Emergency Department, all in-patient consultations, and some if not all referrals to the General Surgery Service from other hospitals via CritiCall. The staff surgeon is typically also responsible for the Trauma Team at the same time.

The staff surgeon is on call for emergencies Monday to Friday from 8 until 5. Emergency patients admitted during the night are initially admitted to the surgeon on call that night and then transferred to the Acute Care Service at 8 am the following morning.

Why was this change in organization of the Division of General Surgery carried out?

Acute Care Services were initially started in the United States five to ten years ago and have now moved to Canada for basically the same reasons. General Surgery has become increasingly sub-specialized and a considerable number of academic general surgeons are no longer comfortable with the management of the entire spectrum of general surgical emergencies. A second driver for the emergence of the ACS in the United States was the malpractice system there. Emergency and trauma patients account for a much larger than average proportion of malpractice suites and many surgeons in the United States wished to avoid that liability. On the other hand, there also exist a significant number of general surgeons who prefer to maintain a wide general surgical practice that includes trauma surgery.

What are the advantages of this new system?

The main advantage to my mind is that it frees up all the other general surgeons who are not doing acute care at any particular time so that they may carry on with their elective clinics, operating schedules and so on, without disturbance by emergency consultations. It also facilitates clinical research involving clinical trials of patients with acute problems, as they are all looked after by a single common service. The Acute Care Service may also have some educational benefit particularly for junior residents. A month or two on the service gives them the opportunity of seeing a large number and wide range of urgent general surgical problems. On the other hand, the senior residents on the service often complain that they don't get to do as much operating as residents on other services. The main disadvantage of this service is the sometimes frequent change of most responsible physician. For example, a patient with an adhesive bowel obstruction might be admitted to Dr. A. at 10 pm on Friday night, transferred to Dr. B. at 8 am on Saturday morning, and then again transferred to Dr. C. at 8 am Monday morning. The patients may have no idea who is actually responsible for their care other than the resident staff. The philosophy of management may also change from day to day as the staff changes, and this is confusing for the patient, the residents, and the nursing staff. Finally, when a patient is admitted with a difficult problem to the Acute Care Service, there can be an unconscious tendency on the part of the staff surgeon to procrastinate knowing that within a few days the patient will be looked after by someone else and hence the surgeon may be able to "dodge the bullet".

In conclusion, there are a number of strong positive features to this system. It certainly benefits academic general surgeons by allowing them the freedom to pursue their specialized interests. It also ensures that emergency patients are cared for expeditiously by surgeons who are specifically interested in their type of problem. To my mind, the main down side is the lack of continuity of care of possibly complex patients. This can be remedied by transferring such patients who will likely be in hospital longer than about a week to the care of one specific surgeon who specializes in their type of problem. This surgeon might be the one who performed the initial emergency surgery or may not. At any rate, it should be very clear to all involved and most importantly to the patient that they are now under the care of one specific surgeon for the rest of their hospital course. This also has the advantage of removing long stay patients from the Acute Care Services and gives the residents better experience of looking after truly emergency situations rather than prolonged convalescence from more drastic emergencies. If managed appropriately, I believe that this system will be an overall benefit for the patients, the residents and the staff.

Robert Mustard

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