Regionalization of Emergency General Surgery: Is Transfer Worth the Risk? The regionalisation of emergency general surgery (EGS) services remains an ongoing point of discussion for surgeons and service managers alike. As with other areas such as trauma, vascular surgery, cancer, MI and stroke services, there are pros and cons to regionalisation with perhaps even less evidence than in the aforementioned specialties to convincingly sway opinion one way or another. EGS patients with their myriads of co-morbidities and complications inevitably require more ITU support and multidisciplinary input which may be more readily provided at specialist units.
The patient population on the whole tend to come from poorer socioeconomic backgrounds with relatively inferior medical facilities who may benefit from direct triage to specialist EGS centers, especially given that emergency care in many hospitals is at breaking point. Also, there is a well described relationship between patient volumes and outcomes, especially for high-risk patients presenting in shock or with peritoneal contamination and vascular injuries.
This volume-outcome relationship has very much being the drive behind the Take The Volume Pledge, an initiative driven by leaders at Dartmouth-Hitchcock Medical Center, Johns Hopkins and the University of Michigan Health System aiming to place limits on emergency surgery being carried out at low volume centres.
On the other side of the arguments there are those who would say that transferring sick patients between hospitals is itself a risk factor for poor outcome and that there is likely to be a knock-on effect on other specialties at designated EGS centres such as delays to theatre for other urgent but less imminently life-threatening conditions. Transferring patients to regional centres where they may be far removed from their own family and social support networks may also be detrimental to the mental wellbeing of patients and their families.
In the UK the model is increasingly moving to one where EGS is its own stand-alone specialty with consultants (attending physicians) focusing their time almost exclusively to the care of these patients, with limited scope for other clinical activities such as lucrative work in the private sector. Not surprisingly, this has led to a negative perception in some quarters, with many surgical trainees shunning the positions which are often filled by foreign graduates or non-trainee surgeons who (for reasons of bureaucracy rather than competency) often struggle to get regular consultant posts in an established and more competitive surgical specialties. No one, not least your average egotistical surgeon wants to be seen as a second- class citizen within their sphere of operation.
The workforce issue is no less a problem back in the US given that there is a dwindling and ever ageing pool of pure general surgeons from which the EGS surgeon cohort is drawn. Of the approximately 1000 general surgery chief residents who graduate annually, only around 300 pursue general surgery careers.
In theory there should be few obstacles to formally establishing centralised EGS centers at hospitals with existing acute care surgery (ACS) programs, combining the critical care and trauma elements with EGS. Before moving full steam ahead with centralisation there is a need for a trusted evidence-based triage tool which can identify the EGS cohort most likely to benefit from transfer and/or those most likely to suffer harm from remaining in their local hospital.
Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.