Prior to July 2005, emergency general surgical care at UCSF was provided by a diverse faculty of gastrointestinal, hepatobiliary, colorectal, oncologic, endocrine, breast, and bariatric surgeons spread across 2 campuses separated by 3 miles, each surgeon taking call on a 24-hour basis.
This system of care was problematic for several reasons. First, daytime consultations disrupted the elective procedures and clinics of on-call surgeons. Patients in the ED or acute care ward might wait hours until the on-call surgeon was available to evaluate them. Second, the diversity of emergency surgical conditions left many surgeons uncomfortable caring for diseases outside their usual practice. Third, the 24-hour structure of the call schedule and separate campuses disrupted continuity of care, particularly for those patients treated by surgeons at the remote site who would need subsequent care in the ED at the main hospital.
Surgical house-staff provided the only continuity and were constrained even more by the 80-hour Accreditation Council for Graduate Medical Education work week. Finally, there was little economic incentive for taking call; the only benefit to a surgeon or the department was revenue generated from the minority of consultations that resulted in a surgical procedure.
Birth of the Program
In 2005, the Acute Care Surgery Program (then called the Surgical Hospitalist Program) was co-founded by a group of surgeons that included Hobart Harris, MD and Jessica Gosnell, MD. They reorganized the acute general surgical service at the UCSF to address the challenges described above. As originally conceived, hospitalists are physicians who dedicate the majority of their time to the care of hospitalized inpatients of primary care providers, with the intent of handing the care back to the primary care physician after the patient is discharged from the hospital.
This model of care was introduced on the medicine services at UCSF in the early 1990s in response to pressures of the managed care movement. Pioneered by UCSF physician Robert Wachter, MD, the medical hospitalist program resulted in improved quality, reduced length of stay, and improved patient safety. By focusing on continuity and comprehensiveness of care, medical hospitalists have made substantial progress in both quality and efficiency improvement efforts for inpatients.
Encouraging Results
Preliminary evidence suggests that increasing expertise in the delivery of surgical care in an emergency setting can lead to improvements in the care of elective patients as well. Longer-range efforts will seek to identify coordinated efforts between medicine and surgery hospitalist programs to maximize hospital efficiencies and to address the national challenges of ED boarding and diversion and inadequate access to emergency surgical care.