The historical successes of emergent vascular care are known to many. The role vascular surgeons have played in providing experienced care in emergent situations has been well documented whether near the battlefield or in our local emergency/trauma centers. Competent vascular surgeons have been providing extensive vascular surgical skills over the years. Recently, I have observed challenges to emergent vascular surgical care and it should come to no surprise as to why.
Vascular surgery in the past 10 years has seen significant changes to the specialty. The endovascular revolution, changes in our training with less general-surgery years and less open-case training, and a shortage of vascular surgeons nationally, has been a concern of many. With the present hospital emphasis on quality, costs, turf wars, and credentialing along with more surgeons focusing on outpatient venous practices and office-based labs, the biggest void in our specialty may be coverage to our emergency rooms. As more senior general surgeons retire and younger general surgeons are not vascular trained, our emergency rooms nationally are at risk of not having appropriate, experienced vascular coverage. The potential consequences are significant when one considers legal ramifications and timely patient care and safety.
While hospitals have clearly documented guidelines for vascular surgical open and endovascular privileges along with variability in reappointment volumes, practice guidelines for emergency room vascular surgical coverage and experience documentation have not been described. How do we assure that we have the most experienced vascular surgeons covering our emergency rooms who are competent in open ruptured AAAs, crescendo TIA care from carotid plaques, penetrating vascular trauma, embolectomies, vascular access bleeding and failed endovascular interventions requiring emergent bypasses for limb salvage?
Vascular surgeons today may not have the open elective volume to do these types of cases to feel comfortable with emergent cases. That is concerning. More concerning is the possibility that the best venous ablator in the community is on call for the next ruptured pararenal AAA at our emergency rooms.
The solutions are not going to be easy but must be considered and well thought out. Hospitals must ensure that appropriate, qualified vascular surgeons with a minimum open experience are covering our emergency rooms. This may require a program in which an inexperienced surgeon is supported with an experienced surgeon as the backup. We must develop the emergency room coverage practice guidelines and ensure that our emergency rooms are covered with the best surgeons for high quality and the best standards for patient safety.
Active participation in a minimum open and endovascular cases along with monitoring of quality with participation in registries like the Vascular Quality Initiative may provide a starting point for hospital coverage guidelines. As vascular surgery evolves in our communities, changes to call assignments, credentialing, and practice guidelines may be required to ensure the most appropriate, skilled vascular surgeons are covering our most unstable patients in the emergency room.