Table 2 Components of Structure and Process Domains

 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

 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

 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