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Table 2 Components of Structure and Process Domains

From: Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach

Domain Component
Structure
 EGS workforce # of staff (nurse-practitioners, physician assistants, residents) caring for EGS patients
# of EGS surgeons
Demographic characteristics of EGS surgeons including sex and career stage (nearing retirement versus newly trained)
Professional characteristics of EGS surgeons including subspecialty training, board certification, and other advanced degrees
Frequency and timing of advanced practice practitioner, surgical resident, or medical student clinical assistance to EGS surgeons
EGS surgeon clinical responsibilities in addition to EGS (e.g., trauma, critical care, burns, elective surgery, other)
EGS surgeon employment models (e.g., academic, private practice)
Financial incentives for EGS coverage including additional pay for overnight EGS coverage and compensation for encounters with uninsured patients while covering EGS
EGS surgeon nonclinical responsibilities (e.g., surgical education, research, community outreach, administration)
 Hospital staff Round-the-clock availability of imaging technologists such as x-ray, ultrasound, and computed tomography technicians
Round-the-clock availability of clinical laboratory and blood bank technicians
Round-the-clock availability of respiratory therapists
Overnight availability of perioperative staff including scrub technicians, OR nursing staff, recovery room nursing staff, and CRNAs
 Subspecialty services Anesthesiologists overnight availability
Surgical pathologists overnight availability
Round-the-clock availability of intensivists
Method of ensuring round-the-clock intensivist coverage (e.g., tele-ICU, on-call in-house)
Advanced endoscopists availability
Interventional radiologists availability within one hour
Process
 Surgeon-patient contact Processes to alert surgeons of an unstable EGS patient in the ER or after surgery
How EGS patients are cohorted within patient censuses (e.g., only among other EGS patient, combined with trauma)
Where EGS patients received care including on regular floors (e.g., dedicated EGS floor, med-surg) and the ICU (e.g., SICU, MICU, med-surg ICU)
Where EGS patients typically receive care including inpatient (e.g., specifically assigned ward, floor with medical patients, surgical or medical ICU) and outpatient (e.g., dedicated EGS follow-up clinic)
Overnight EGS surgeon in-house
Daytime EGS surgeon coverage model (e.g., “on-service” or shift of defined length) including length of continuous EGS coverage
Daytime surgeon or post-call surgeon freed from other responsibilities
EGS surgeon salary incentives such as surgeon compensation for encounters with uninsured patients or for taking call
Transfer agreements to send and/or receive EGS patients including approximate volume of transferred patients
 Communication Face-to-face hand-offs (e.g., timing, attendees, patients discussed)
Alternatives to face-to-face hand-offs (e.g., telephone call, sending an email)
Communication of critical results to surgeon by radiologist
 Continuity of care Likelihood of overnight surgeon providing EGS operation rounding on patient until discharge
Likelihood of overnight surgeon providing EGS operation seeing that patient in follow-up clinic
Likelihood of overnight surgeon providing EGS operation providing care if patient is readmitted
Whether operating surgeon or surgical colleagues provide surgical critical care to EGS patients
Presence of outpatient clinic specifically for EGS patients
Frequency of transfer of EGS care (non-operative, post-operative, or post-discharge) to other clinicians including hospitalists, primary care physicians, and subspecialists
 EGS team implementation Overall EGS coverage model: dedicated team, tradition general surgeon on-call approach, other
Daytime EGS surgeon coverage model (e.g., “on-service” or shift of defined length) including length of continuous EGS coverage
Dedicated EGS team oversight (e.g., Division, Section), age (ie. date first implemented), and name/title of team
EGS team composition by profession (e.g., surgeons, advanced practice practitioners) and stage of training (e.g., trainees, students, faculty)
EGS coverage responsibilities (e.g., also covering trauma) or lack thereof (e.g., free of office responsibilities)
Frequency and timing of advanced practice practitioner (NP, PA), surgical resident, medical student clinical assistance to EGS surgeons
 Operating room access # of operating rooms per the American Hospital Association survey
Daytime “block” time (number of days) for EGS cases
Tiered process for booking urgent or emergent cases
Guidelines to defer elective operations for emergent cases
EGS surgeon’s work schedule constraints including other clinical responsibilities, length of shifts, and post-call coverage
Surgeons’ overnight coverage patterns including being in house, covering trauma, covering ICU, and covering at more than one hospital
Overnight operating room availability
Type and availability of overnight perioperative staff (e.g., scrub technicians, OR nursing staff, recovery room nursing staff)
 Patient safety protocols Activation system for unstable EGS patients in ER and guided response strategies to identify at risk EGS patients generally
Guidelines to escalate care when patients deteriorate
Protocols to address emergent patient care including anticoagulation reversal, massive transfusion, airway access, and emergent OR access
Round-the-clock availability of physicians and specialized, rapid response teams to evaluate and manage deteriorating patients
Processes for communicating critical patient information including radiographic findings and face-to-face signoffs
Transfer agreements to send EGS patients to higher resourced hospitals
Transfer agreements to facilitate round-the-clock critical care coverage
 Performance improvement measures Audits for return to OR during index hospitalization or within 30 days of discharge
Audits for operation within 30 days of non-operative management of an EGS condition
Audits for re-admission within 30 days after discharge
Audits for return to ICU within 48 h of transfer to floor/ward
Process to monitor time to initial evaluation after EGS consultation, time to OR after booking emergent case, and time to source control after determining EGS diagnosis
Program managers for EGS patients with or without other responsibilities
Prospective EGS registry
Implementation of morbidity and mortality conference for EGS patients as dedicated M&M or integrated into existing M&M, including frequency and who attends
Combined Elements: Structure and Process
 Diagnostic radiology Imaging technology available per the American Hospital Association survey
Round-the-clock availability of imaging technologists such as x-ray, ultrasound, and computed tomography technicians
Timeliness of study completion and read, including xray, ultrasound, and computed tomography
Communication of critical results to surgeon by radiologist
Use a tele-radiologist to read imaging studies overnight
Interventional radiologists availability within one hour
 Critical care resources # of medical-surgical ICU beds per the American Hospital Association survey
Availability critical care physicians and surgeons practicing critical care
Who provides critical care for EGS patients (e.g., surgeon or pulmonary intensivist)
Location where EGS patients receive care (e.g., SICU vs MICU)
Round-the-clock availability of respiratory therapists
Protocols in place to ensure urgent availability of blood products
Protocols in place to identify post-op EGS patients requiring ICU admission
Protocols to ensure rapid-response teams to provide airway access
Protocols to ensure adherence to the Surviving Sepsis Campaign® guidelines
Availability of round-the-clock physicians and specialized, rapid response teams to monitor unstable patients and establish airway access
Round-the-clock availability of intensivists
Method of ensuring round-the-clock intensivist coverage (e.g., tele-ICU, on-call in-house)
EGS surgeons’ critical care credentials including board certification and additional fellowship training