title: Nontrauma emergency surgery: optimal case mix for general surgery and acute care surgery training.
abstract: BACKGROUND
  To examine the case mix and patient characteristics and outcomes of the nontrauma emergency (NTE) service in an academic Division of Acute Care Surgery.
  
  
  METHODS
  An NTE service (attending, chief resident, postgraduate year-3 and postgraduate year-2 residents, and two physician assistants) was created in July 2005 for all urgent and emergent inpatient and emergency department general surgery patient consults and admissions. An NTE database was created with prospective data collection of all NTE admissions initiated from November 1, 2007. Prospective data were collected by a dedicated trauma registrar and Acute Physiology and Chronic Health Evaluation-intensive care unit (ICU) coordinator daily. NTE case mix and ICU characteristics were reviewed for the 2-year time period January 1, 2008, through December 31, 2009. During the same time period, trauma operative cases and procedures were examined and compared with the NTE case mix.
  
  
  RESULTS
  Thousand seven hundred eight patients were admitted to the NTE service during this time period (789 in 2008 and 910 in 2009). Surgical intervention was required in 70% of patients admitted to the NTE service. Exploratory laparotomy or laparoscopy was performed in 449 NTE patients, comprising 37% of all surgical procedures. In comparison, only 118 trauma patients (5.9% of admissions) required a major laparotomy or thoracotomy during the same time period. Acuity of illness of NTE patients was high, with a significant portion (13%) of NTE patients requiring ICU admission. NTE patients had higher admission Acute Physiology and Chronic Health Evaluation III scores [61.2 vs. 58.8 (2008); 58.2 vs. 55.8 (2009)], increased mortality [(9.71% vs. 4.89% (2008); 6.78% vs. 5.16% (2009)], and increased readmission rates (15.5% vs. 7.4%) compared with the total surgical ICU (SICU) admissions.
  
  
  CONCLUSIONS
  In an era of declining operative caseload in trauma, the NTE service provides ample opportunity for complex general surgery decision making and operative procedures for surgical residency education, including advanced surgical critical care management. In addition, creation of an NTE service provides an optimal general surgery case mix, including major abdominal operations, that can augment declining trauma surgery caseloads, maintain acute care faculty surgical skills, and support general and acute care surgery residency training.
authors.affiliation: Division of Acute Care Surgery and Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.
authors.forename: Jill R
authors.initials: JR
authors.lastname: Cherry-Bukowiec
authors.forename: Barbra S
authors.initials: BS
authors.lastname: Miller
authors.forename: Gerard M
authors.initials: GM
authors.lastname: Doherty
authors.forename: Melissa E
authors.initials: ME
authors.lastname: Brunsvold
authors.forename: Mark R
authors.initials: MR
authors.lastname: Hemmila
authors.forename: Pauline K
authors.initials: PK
authors.lastname: Park
authors.forename: Krishnan
authors.initials: K
authors.lastname: Raghavendran
authors.forename: Kristen C
authors.initials: KC
authors.lastname: Sihler
authors.forename: Wendy L
authors.initials: WL
authors.lastname: Wahl
authors.forename: Stewart C
authors.initials: SC
authors.lastname: Wang
authors.forename: Lena M
authors.initials: LM
authors.lastname: Napolitano
mesh_terms: D018806:APACHE; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D003953:Diagnosis-Related Groups; D004635:Emergency Medicine / Q000193:education*; D004638:Emergency Treatment; D005260:Female; D013502:General Surgery / Q000193:education*; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010359:Patient Readmission / Q000706:statistics & numerical data; D011446:Prospective Studies