Can you please come to theatre now? – A retrospective review of emergent intra-operative vascular assistance in a tertiary centre

Vascular surgeons are frequently requested to assist surgeons and proceduralists from different specialties, and provide support with anatomic exposure, oncologic resection, and repair of vascular injury.^{1, 2} In the emergent setting, vascular surgeons may be required to attend immediately due to uncontrolled bleeding, or compromised organ or limb perfusion. These calls can cause significant disruption to scheduled commitments, require vascular surgeons to remain in close proximity to the hospital, or necessitate the involvement of surgeons who are not on-call. Understanding that vascular surgeons are needed to provide intra-operative assistance to colleagues may guide trainee skill acquisition and influence hospital rostering.³

The vascular surgery workforce is the second smallest surgical subspecialty in numerical terms in Australia and Aotearoa New Zealand (ANZ).⁴ In 2021, there were 241 surgeons as members of the ANZ Society of Vascular Surgery (including 26 in New Zealand), with the majority practicing in metropolitan and tertiary hospitals.⁵ This raises concern for a potential Australasian vascular surgeon staffing crisis - in the context of a growing burden of vascular disease from both an aging population as well as an increasing prevalence of obesity, diabetes mellitus and renal failure.⁶ Incongruence between a small vascular workforce and growing demand for services is also being seen in the United States and United Kingdom.^{7, 8} It is therefore important to accurately define the burden of elective and acute work received through formal and informal referral pathways to allow professional bodies and institutions to make provisions for providing a sustainable vascular service.⁴

Currently, there is no published data concerning intra-operative vascular assistance in ANZ. While international reports are useful,^{1, 3, 9} ANZ health systems are unique in that they are a mixed public-private model. In Australia, public vascular care is delivered through Medicare and Health Care Agreements, and in New Zealand this is delivered through Te Whatu Ora and Regional Health Authorities.^{10, 11} In these public hospitals, billing processes may mean intra-operative vascular consultations are under-reported. For this reason, a prospective observational study was performed with the aim of answering the question: “how frequently are vascular surgeons asked to emergently attend another operating room, and what are the characteristics of these cases?”

This study involved a single vascular surgeon in a tertiary vascular centre over a 16-month period ending September 2021 in Aotearoa New Zealand (Health and Disability Ethics Committee Reference 2022 OOS 13139). Cases were included as a ‘Can You Come Now’ case if the participating surgeon was required to attend a non-vascular operating theatre (or procedure room) and consult or operate on an emergent basis within ‘office hours’ (7 am to 5 pm on weekdays). Elective or acute cases where vascular involvement was planned pre-operatively and vascular surgery cases performed by interventional radiologists were excluded.

Over the study period, there were 68 weekday on-call shifts worked by the studied surgeon, during which 17 ‘Can You Come Now’ cases were attended. This amounted to 1 case per 4 on-call weekdays. Over half the calls for assistance were from Cardiology (8/17), followed by Orthopaedics (5/17), Trauma/General and Cardiothoracic surgery (2/17 each). Most consults were for bleeding (10), 5 were for vessel occlusion and 2 for access/exposure. The studied surgeon was required to perform an immediate surgical intervention in 13 cases, and of those, open surgery was utilized in 9 cases. There was one hybrid solution required in the Cardiac Catheterisation Lab. The femoral region was the most involved anatomical site, though subclavian, axillary, popliteal, abdominal, iliac and the forearm were also included. Of the 4 cases that did not require intervention at the time of initial review, two had a return to theatre on the same day for a vascular operation. There was one intra-operative death due to uncontrolled pelvic venous bleeding. There were no other mortalities within 30-days.

In this single centre study, the vascular service was frequently asked to attend other theatres emergently, to provide crucial intra-operative assistance by a range of specialties in a broad array of anatomic areas. The resulting impact from this unplanned work could be considered across three broad domains: the surgeons and their departments, institutions, and the broader profession.

The length of time and level of involvement from the vascular surgeon and their team is not easily measurable or well documented, as acute intra-operative referrals may not be captured routinely in hospital administrative databases or national audit systems. Some studies have shown this unplanned involvement to be time and labour intensive, though there is little data on the impact on pre-existing elective commitments.^{1, 9}

Research has shown that vascular surgeons are important in an institution's ability to offer safe and prompt surgical care in the modern environment.¹² These results raise the question as to whether an on-call vascular surgeon should be available onsite during office hours, with no competing commitments, in tertiary hospitals conducting major elective surgery. One step towards quantifying the resource cost to the surgeon and institution would be to initiate robust tracking and monitoring systems for ‘Can You Come Now’ cases. From this data, institutional decisions could be made regarding safe surgeon rostering, ensuring the immediate availability of a vascular surgeon and, more broadly, facilitate strategic workforce development.^{3, 12} This study was carried out in a publicly funded health system so billing data was not collectible. In other regions with private health models, through the provision of operative assistance, vascular surgeons have been shown to provide significant financial value to their hospitals.^{13, 14}

‘Can You Come Now’ cases in this study warranted immediate expertise – calling upon a broad range of skills in a breadth of anatomic regions. Recently there has been a trend towards increasing endovascular practice¹⁵ and acknowledgment of a reduction in exposure to open surgery for trainees in ANZ.^{16, 17} The requirement to provide emergent assistance reinforces the need for training models to continue to prioritize a balance between open and endovascular techniques, and recognizes that vascular surgeons may be required to operate outside of the hybrid theatre.

Vascular surgeons provide crucial and frequent emergency operative support across multiple specialties, and this support has wide-ranging implications for surgeons, institutions and the profession.