BACKGROUND: Acute care surgery (ACS) was proposed to address a general surgery workforce crisis; however, the ACS workforce composition is unknown. A national survey was conducted to determine the differences in the emergency general surgery (EGS) workforce between ACS and non-ACS hospitals. METHODS: The American Hospital Association (AHA) Annual Survey of Hospitals database was queried to identify acute care general hospitals. A hybrid mail/electronic survey was sent to 2811 acute care hospitals that met the inclusion criteria of hospitals that care for adult patients ( > /=18 years old) with an emergency room (ER), > /= 1 operating room (OR), and 24-h ER access. Hospitals were queried on whether they utilized an ACS model. The workforce composition among ACS and non-ACS hospitals was evaluated using X(2) tests, t tests, and Wilcoxon rank-sum tests. RESULTS: Survey response was 60% (N=1690). ACS hospitals had a higher proportion of emergency surgeons who were female (20% vs. 14%, p < 0.0001), newly-trained (17% vs 10%, p < 0.0001), critical care trained (78% vs. 31%, p < 0.0001), and who had an additional degree (35% vs. 13%, p < 0.0001). More ACS hospitals had 24/7 in-house OR nursing staff (72% vs. 15%, p < 0.0001) and ancillary staff. CONCLUSIONS: ACS and non-ACS hospitals differ in their surgical workforce. It is clear that ACS hospitals have more human capital, which suggests that ACS hospitals may require more dedicated resources compared to non-ACS hospitals.

BACKGROUND: Acute care surgery (ACS) was proposed to improve emergency general surgery (EGS) care; however, the extent of ACS model adoption in the United States is unknown. A national survey was conducted to ascertain factors associated with variations in EGS models of care, with particular focus on ACS use. METHODS: A hybrid mail/electronic survey was sent in 2015 to 2,811 acute care hospitals with an emergency room and an operating room. If a respondent indicated that the approach to EGS was a dedicated clinical team whose scope encompasses EGS (+/- trauma, +/- elective general surgery, +/- burns), the hospital was considered an ACS hospital. RESULTS: Survey response was 60.1% (n=1,690); 272 (16.1%) of these hospitals reported having used an ACS model of care for EGS patients. Teaching status and general hospital practices (for example, interventional radiology available within one hour) were associated with ACS use. In bivariate analyses, ACS use was associated with many EGS-specific practices (40.1% of ACS hospitals freed their surgeons of daytime clinical responsibilities after operating overnight vs. 4.7% of general surgeon on call (GSOC) hospitals; p < 0.0001). CONCLUSION: There are wide variations in EGS practices in the United States, with use of an ACS model of care being relatively low despite reported benefits of ACS models of care on EGS access, quality, and costs. Hospital factors associated with using ACS models are overall size and higher level of existing resources. These findings could be applied to the development of centers of excellence for EGS care. reserved.

Objective: More than 266 million courses of antibiotics are dispensed to outpatients annually in the US, with the rising elderly population consuming a substantial number of antibiotics. At least 30% of these antibiotics prescribed are unnecessary. Alterations in gut microbiome are known to cause stomach and small intestine (SSI) perforations. However, the impact of antibiotic exposure outcomes of SSI perforations among the elderly has not been studied. We examined the relationship between antibiotic exposure, as a proxy for microbiome modulation, and SSI perforation outcomes in a nationwide sample of elderly patients. Methods: A 5% random sample of Medicare beneficiaries (2009-2011) was queried to identify patients with SSI perforations. Previous outpatient antibiotic exposure (0-30, 31-60, 61-90 days prior to admission) was assessed. Clinical characteristics were compared between no previous antibiotic exposure (NPA) and previous antibiotic exposure (PA) patients. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay and 30-day readmission. Univariate and multivariable regression analyses were performed. Results: Overall, 401 patients ≥ 65 years had SSI perforations (68.3% with NPA and 31.7 % with PA). Mean age (± SD) was 80 years (± 8). Overall in-hospital mortality was 13%. There was a significant difference in the rates of mortality (12% in NPA vs. 18 % in 0-30 days PA, 17% 31-60 days PA, and 8% 61-90 days PA, P= 0.002). After adjustment of other factors, a trend toward increased in-hospital mortality was observed among patients in 0-30 days PA (odds ratio [OR] 2.0, 95% confidence interval [CI] (0.9, 4.7) and was significantly associated with ICU admission (OR 4.3, 95% CI (1.8, 10.2). Conclusion: Recent antibiotic use increases illness severity and may increase mortality among elderly patients with SSI perforations. Exposure to antibiotics, one of the most modifiable determinants of microbiota, should be minimized in the outpatient setting.