Association of Women Surgeons: Clinical Science

Utilization of morning report bresults from a qualitative stud

s,

Medical School, 55 Lake AvenueMassachusetts Medical School,

KEYWORDS:Morning report;Acute care surgery;ACS;Performance

CONCLUSIONS: Morning report is underused among ACS programs; however, if implemented stra-

models of care.1 The advent of resident duty-hour munication to the forefront of national attention.13 The

duty-hour restrictions have forced surgery departments toconsider measures to consolidate trainee education time

1,3,8,1016

of the National Institutes of Health.

The authors declare no conflicts of interest.

The American Journal of Surgery (2013) 206, 647-654* Corresponding author. Tel.:11-508-856-1168; fax:11-508-856-4224.impact of interphysician communication on the quality ofpatient care has been well documented.110

Duty-hour restrictions have challenged training pro-grams to educate their residents in less time whilemaintaining continuity of care for patients.14,69 Althoughthe bulk of patient handoff literature is generated from in-ternal medicine and emergency medicine departments, the

The research reported in this publication was in part supported by a

University of Massachusetts Clinical Scholar Award (to Dr Santry) through

the National Center for Advancing Translational Sciences of the National

Institutes of Health under award numbers UL1RR031982,

1KL2RR031981-01, and UL1TR000161. The content is solely the respon-

sibility of the authors and does not necessarily represent the official viewsThe rigor of patient handoffs has come under increasingscrutiny as more and more providers adopt shift-based

restrictions has increased the total number of patient hand-off interactions and has brought the issue of sign-out com-tegically, it may improve patient care and resident education. 2013 Elsevier Inc. All rights reserved.improvement;Communication;Medical team systemsE-mail address: heena.santry@umas

Manuscript received June 1, 2013; r

0002-9610/$ - see front matter 2013http://dx.doi.org/10.1016/j.amjsurg.20dical School, Worcester, MA, USA; Department of Surgery, University of MassachusettsNorth, Worcester, MA, USA; cDepartment of Quantitative Health Sciences, University ofWorcester, MA, USA

AbstractBACKGROUND: The rigor of handoffs is increasingly scrutinized in the era of shift-based patient

care. Acute care surgery (ACS) embraced such a model of care; however, little is known about handoffsin ACS programs.

METHODS: Eighteen open-ended interviews were conducted with ACS leaders representing diversegeographic and practice settings. Two independent reviewers analyzed interviews using an inductiveapproach to elucidate themes regarding use of morning report (using NVivo qualitative analysis soft-ware).

RESULTS: Twelve of 18 respondents reported using morning report, but only 6 of 12 included at-tending surgeontoattending surgeon handoffs. One of 12 incentivized attending surgeons to partici-pate, 2 of 12 included nursing staff members, and 2 of 12 included physician extenders. Cited benefitsof morning report were safe and effective information exchange (2 of 12), quality improvement (2 of12), multidisciplinary discussion (1 of 12), and resident education (2 of 12). Three of 12 respondentscited time commitment as the main limitation of morning report.aUniversity of Massachusetts Me bPatricia L. Pringle, M.D.a, Courtney Collinsmemorial.org

evised manuscript July 19, 2013

Elsevier Inc. All rights reserved.

13.07.012y acute care surgery teams:y

M.D.b, Heena P. Santry, M.D., M.S.b,c,*and expedite patient handoffs. In the context ofduty-hour restrictions, some general surgery programs

he Ahave shown that morning report can be an opportunity toeffectively educate residents as well as transfer care ofpatients.2,8

In parallel with this growing consideration of morningreport as an opportunity to enhance interphysician commu-nication and patient hand-offs, acute care surgery (ACS)has emerged as a new general surgery subspecialty,encompassing the care of patients suffering from injuriesand nontrauma surgical emergencies (NTSEs) as well assurgical critical care. Modeled after nearly 40 years ofevidence on team-based trauma care, ACS has been shownto improve operating room utilization and departmentalrevenues while reducing emergency room wait times, timeto operation, length of stay, and mortality for NTSEswithout adverse effects on injured patients.1726 However,little is known about how ACS teams ensure interphysiciancommunication and patient handoffs.

Anecdotally, trauma programs have long used morningreport to present new patients and discuss existing patients.Thus, it is possible that some of the benefits of the ACSmodel for patients with NTSEs are due to improved patienthandoffs and enhanced interphysician communication dur-ing morning report. Given the absence of data on whetherthe practice of morning report has been carried forward inthis new surgical subspecialty, we undertook a qualitativestudy to describe how, if at all, centers with ACS programsare using this tool. This was an exploratory study designedto increase our understanding of the perceived advantagesand disadvantages of morning report within the new modelof ACS.

Methods

We conducted a qualitative study to describe the utili-zation of morning report in ACS programs implemented invaried geographic locations and practice settings.

Participants

A purposive sampling method was used to recruit seniorleaders who would be able to describe how they hadimplemented ACS programs. Specific geographic regions(the Mid-Atlantic, the Midwest, New England, the North-east, the South, and the West) and practice types (commu-nity, public or charity, university) were targeted to ensure adiversity of opinion for comparison such that each regioncontained a respondent from each of the 3 types of practicesettings. Potential respondents were selected from the ranksof national organizations or recommended by colleagues. Inother words, once a geographic region was selected, wecontacted department chairs who were known to us athospitals with the targeted practice type for recommenda-tions on who at their institutions was in charge of ACS, ifindeed their hospitals had implemented ACS. If we did nothave a professional contact at a targeted site, we used the

648 Trosters of national surgical associations to make similarinquiries. Sites without ACS teams were not included.Recommended leaders at the remaining sites were con-tacted by e-mail and asked to participate in face-to-faceinterviews about how they practice ACS at their hospitalsfor a qualitative research study on ACS practice patterns.Strict measures to ensure confidentiality were implementedand described to participants. An agreed-upon date andtime for an interview was considered a waiver of writteninformed consent. This study was deemed exempt from fullreview by the institutional review board of the University ofMassachusetts Medical School.

Interviews

One investigator (H.P.S.) created the semistructuredinterview on the basis of clinical experience and anextensive literature review. The interview addressed a rangeof topics concerning ACS practice patterns: infrastructure,communication, team structure, evolution of ACS, andresources (see the Appendix). The interview was piloted onsenior acute care surgeons at centers familiar to the inves-tigator and altered in an iterative fashion. Between June2011 and December 2011, this investigator conducted 18in-person interviews of these ACS leaders who had previ-ously agreed to participate. Fourteen of the 18 participantswere current section chiefs or division chiefs for traumasurgery and/or emergency general surgery, 2 participantswere department chairs, and 2 were senior surgeons at theirsites. All sites had Accreditation Council for GraduateMedical Education general surgery residencies, and 13 siteshad Accreditation Council for Graduate Medical Educationsurgical critical care fellowships at the time the interviewswere conducted. None had been formally approved by theAmerican Association for the Surgery of Trauma for anACS fellowship at the time. The interview questions wereopen ended, and the interviewer asked for further explana-tion whenever clarification was needed. Interviews tookfrom 19 to 84 minutes to complete. Interviews were audiorecorded with participants consent, transcribed, and im-ported into NVivo version 10.0 (QSR International, Mel-bourne Australia) for qualitative data analysis.

Data analysis

In conducting our interview analyses, we relied heavilyon the qualitative research principles of grounded theory,also known as the inductive approach.27 The principle of re-flexivity was used to better understand our preconceptionsto decrease bias in both the interviewing and data analysisstages.28 Also, we used the strategy of investigator triangu-lation, whereby team members from diverse backgroundsanalyze the raw data to minimize the personal or disciplin-ary bias of a single researcher.29

In the first step of analysis, 2 investigators (P.L.P. andC.C.) independently reviewed each interview transcript. As

merican Journal of Surgery, Vol 206, No 5, November 2013concepts emerged from the data, the coders used NVivo to

code specific lines of text to their corresponding concepts(ie, open coding). The 2 initial coders met to comparecodes, resolve discrepancies, and review the taxonomy ofcodes. The constant comparative method of qualitativeanalysis30 was used to compare coded segments of text toexpand on existing concepts and identify new themes.Codes were refined until we reached theoretical saturation,with a final taxonomy of 50 codes. This final taxonomy ofwas applied to all of the transcripts by the 2 initial coders,after which there was found to be 98% intercoder agree-ment. In the second step of analysis, a third investigator(H.P.S.) reviewed disputed responses until 100% agreementwas reached.

The results presented below represent the relationalanalysis of responses pertinent to interphysician communi-cation and patient handoffs, whether or not morning reportwas implemented at the respondents hospital, broken downby theme and quantified to represent response density (eg,number of respondents holding similar views, conductingsimilar practices, or providing similar comments).

Results

Twelve of 18 respondents reported that their ACSprograms conduct morning report. There were many var-iations in both processes and perceptions of morning reportas evident by diversity of responses detailed below. Fewperceptions were held or processes described by a majorityof respondents.

Structure and content of morning report

Eight of the programs with morning report specifiedattending surgeon presence, with 6 respondents reportingthat both the daytime attending surgeon coming on serviceand the overnight attending surgeon signing off serviceparticipated in morning report. One respondent spoke aboutincentivizing attending surgeon attendance at morningreport: Everything has sign-in sheets. We monitor thenumber of times you have been there. We actually incen-tivize our faculty financially to make sure that there arecertain goals [to attend handoffs]. Another noted thatmorning report is mandatory: All the faculty are expectedto be present at all of the hand offs. Fellows are present. Allfaculty mandatory. Mandatory for the guy coming on call orcoming off call, but everybody shows up.

One program sends the overnight resident home beforemorning report while the overnight attending surgeon stays.Another specifically removes the chief residents frommorning report to afford them more operative time: [Thechief resident] already has pretty much all their inteland.weve unburdened the chief from the morning reportbecause we really want them operating.

Two respondents mentioned the inclusion of intensivecare unit (ICU) and floor nursing staff, and 2 respondents

P.L. Pringle et al. Acute Care Surgery Morning Reportmentioned the inclusion of midlevel staff, such as physicianassistants (PAs). One program was unique for involving,nurse managers and/or charge nurses from the wards, OT/PT [occupational therapy/physical therapy], nutrition, phar-macy, social work, every single day..We have casemanagers and social workers there to help us with dis-charge planning. We have our PI [performance improve-ment] manager and our trauma program manager there tocapture PI events and incidents.

Two programs reported an open invitation to surgicalsubspecialties: We have invited representatives of theorthopedic and other surgical teams to come along and theyusually only come along when there are significant issuesor so. And another program noted, we have one of thePAs from orthopedics, who attends every day. The chair-man of orthopedics and his residents come on Tuesday totouch base about plans for the week for the orthopedics.

Institutions with separate teams for trauma patients andemergency general surgery patients appear to be conductinga single morning report among both teams. For example,Both Trauma attendings have to be there at 7:00. Theemergency surgery attending makes an appearance by7:30..If you cannot be there, if you have got to be inthe operating room, you have to send your senior residentand your junior resident because you have got to get someinformation.

Two ACS programs were unique in their use of tools tofacilitate morning report. One used a computer-based tool:The residents have a program where they upload data forhanding off.the weekends are.a big opportunity for lackof continuity. Especially if you get like a [omitted to protectcenter identity] guy and then another per diem guy comingin. Theres a lot of opportunity for missed information.Another uses a low-tech tool: We actually use a checklistto go through the various aspects of morning report, justlike a cockpit.

The interviews revealed variation among ACS programsin the types of patients discussed at morning report. Severalrespondents emphasized that their morning report includeddiscussion of the sickest, most critically ill patients on theservice. Three respondents specifically included sign-out ofICU patients at morning report: Were hearing about firstnew admissions to the ICU and then any ICU problems andthen they peel off. For 3 respondents, morning reportserved mainly as a way to review new patients and salientovernight events: Whats happened overnight, new ad-missions, any problems the patients have. In contrast,1 respondent reported that morning report served as a morecomprehensive overview of all patients on the service: Wego through the whole last twenty-four hours of trauma andacute care surgical encounters.not just admissions, butencounters, the whole gamut of trauma and acute care. And,then we discuss during that time issues on the floor andissues in the ICU.

Three respondents reported including consults in morn-ing report. One respondent specified that morning reportserves as an opportunity to discuss the operative cases for

649the day: Every single consult and every single case being

passed on and every single case being put on the board [forsurgery] is reviewed. Another used morning report as anopportunity to create a plan for the day: Morning report iswhere the patient hand-off occurs, the plan for the day foreverything is structured.

One program was unique in that its morning reportincluded time to discuss follow-up from the outpatientsetting: They also discuss patients that came back into theclinic [with] interesting follow-up or issues from thatstandpoint.

Advantages and disadvantages of morning report

Throughout the interviews, respondents described vari-ous perceived benefits of morning report. Respondentsreported that morning report allows for effective and safeexchange of information (2 of 12), in some cases byaddressing anticipated problems for the day (1 of 12).Respondents also reported that morning report served as aquality improvement opportunity (2 of 12), a forum formultidisciplinary information exchange (1 of 12), and anopportunity to provide trainee education (2 of 12). Oneprogram was unique for having an attending surgeon notinvolved in a case be the discussant during morning reportto facilitate quality improvement (1 of 12). Morning report

was closely linked to continuity of care (3 of 12), inparticular in the context of duty-hour restrictions (1 of 12)and change of on-service attending surgeon (1 of 12). (SeeTable 1 for specific quotations supporting these themes.)However, not all respondents had positive comments aboutmorning report. Three respondents commented that morn-ing report was cumbersome, torture, and redundant.

Alternatives to morning report

Six of the 18 programs examined in this study do not usemorning report. The respondents from those programsdescribed several alternatives to morning report, all ofwhich involved the passing on of patient information, whilenone included opportunities for teaching.

Most of the alternatives to morning report consisted ofthe attending surgeon coming off the service reaching outto the attending surgeon coming onto the service. Onerespondent described the method simply as, I think at thefaculty level we just talk to each other every day. Usuallythe attending surgeontoattending surgeon conversationdoes not take place in person: It is usually by phone brief,whatever happened. It used to be person to person that doesnot always happen. It is usually a pretty brief what are thefires that you dealt with over the evening. Several

Table 1 Key quotations exemplifying advantages of morning report (n 5 12)

lary

at allices.the sgooyou

ressedes the itshoue doasesthe

th thgn thrting

We know we IM

w, atn get input from somebody who says, oh yeah. I did that operationweekk ortomohairmabok theormaldnto, if

650 The American Journal of Surgery, Vol 206, No 5, November 2013or thkno

We catwoweeanas

To discuss patients with surgical subspecialty teams The cbase

For trainee education I thinperfshouwe dTheme Exemp

For the effective and safe exchange of information So thserv

It isTo proactively address problems for the day ahead It is a

timeaddmak

For performance improvement We usthatit, w

The cwith

To provide better continuity of care in the context ofnew resident work-hour restrictions

So widesirepos ago even though they may not be working on the team thisthey may be in some other role but they can say, yeah, thatsis was shaky to begin with or whatever.an of orthopedics and his residents come on Tuesday to touchut plans for the week for the orthopedics.res a bunch of teaching that goes on in there and we use it fornce improvement. If something happened last night thathave, we identify the issue. If we can dodif we can resolve it,we cant, we start the investigation piece.quotations

seven of us [attending surgeons] know all 60 patients on bothThat way the trauma back-up guy knows whats going on.afest way to ensure a clean hand-off.d meeting. It is about an hour meeting in the morning and by theleave that meeting there are no surprises. Everything has been, you know where the problems are for the day and it reallye day go a lot smoother.for performance improvement. If something happened last nightldnt have, we identify the issue. If we can dodif we can resolve, if we cant, we start the investigation piece.are discussed every morning by an attending that is not involvedactual care.e new intern rules, what we have done is we have been able toeir night float start so that it can actually stay for morning, at least hear about the cases.ho is going to be downgraded from the ICU to come to the WardC and we are all at least hearing what has been happening so weleast, for better continuity of care from that standpoint.

from programs using morning report echoed these findings

by suggesting that, as a designated handoff moment forACS teams, it ensures effective and safe exchange of infor-mation and improves continuity of care at both the residentand attending surgeon levels.

Although there was a lack of uniform agreement amongour respondents, their various remarks do suggest 2 mainways that morning report can achieve these benefits. First,including both the signing-off and receiving teams in morn-ing report appears to ensure that key details are not missed inpatient handoffs. Second, including multiple residents andattending surgeons who have cared for a patient, in the pastand present, appears to ensure that information does not getrespondents reported an emphasis on sick patients in thesign-out: Were just making the phone call. I see I got thissick person, this sick person and thats it. Finally,1 respondent described obtaining input from other attend-ing surgeons, even without a morning report in place: Wehavent really needed it because we work so closelytogether. If theres a sick patient we talk about it first thingin the morning, we e-mail each other, we talk..I alwayswant to get the opinion of other people about what Imdoing or what I did, so we work so closely together, we justtalk every day about the patients.

Comments

In our experience, trauma programs routinely usedmorning report, even before the 2003 national duty-hourrestrictions and the advent of ACS as a specialty. Becausethe ACS model is rooted in the specialty of trauma,31 it isnot surprising that we found that a majority of centers inour study had some form of morning report in place at theirACS programs. However, we found that the tradition ofmorning report has been variably carried forward withoutany consistent processes or perceptions of morning reportamong our respondents. Nevertheless, the qualitative dataon morning report gleaned from these 18 surgeons leadingACS programs in various geographic locations and practicesettings provide important consideration for our professionat a time when continuity of care has increasingly become aconcern, in particular among surgical residencies, acrossthe country.24,6,7,9,10

In multiple settings,1,6 including general surgery pro-grams,10 in-person patient handoffs have been found to beof higher quality for maintaining continuity of care and pre-venting errors than other modes of communication. A re-view by the Handoff Task Force of the Society ofHospital Medicine Healthcare Quality and Patient SafetyCommittee recommended creating a formally recognizedand in-person handoff plan instituted at the end of a shiftor change in service (class 1, level C evidence).1 While im-plementing these recommendations, 1 surgery programfound that 84% of its residents viewed morning report asan effective tool for patient handoffs.8 Our respondents

P.L. Pringle et al. Acute Care Surgery Morning Reportlost over time. These benefits are particularly important forpatients transitioning from 1 level of care to another and forpatients with previous operations, where the intraoperativedetails from the past continue to be relevant to ongoing care.For example, unwritten or underemphasized informationfrom a previous operation could play a role in a patientsmanagement, such as changing the teams threshold tooperate or influencing the current operative plan.

Surprisingly, not all 12 sites using morning report citedenhanced communication and improved continuity as abenefit. Failure of leadership to recognize this benefit,along with comments begrudging the time spent in morningreport, suggests that in-person handoffs are underappreci-ated. Furthermore, it is possible that programs without in-person handoffs have poorer quality handoffs, even thoughtheir leaders believe that telephone conversations on keyissues are sufficient. Additional research on the quality ofsurgical handoffs, especially in the acute setting amongsurgeons with competing interests (eg, operating roomtimes, ICU rounding blocks), is needed.

In addition to maintaining continuity, morning reportalso has potential to serve as a forum for daily peer-to-peerfeedback and continuous quality improvement. Whenattending surgeons and other team members not directlyinvolved in a case can offer real-time second opinions, careplans may be modified and potential morbidity avoided.The quality and relevance of surgical morbidity and mor-tality conferences in the modern era has come underquestion in recent years.32 In these traditionally weekly(or at times less frequent) conferences, errors are discussedafter they occur, and modifications are adopted to preventrecurrence in future patients. Our respondents suggestthat peer-to-peer feedback during daily morning reportscould be a major advantage over morbidity and mortalityconferences by allowing earlier detection of potential com-plications and facilitating rescue of current patients to pre-vent or reduce morbidity and mortality.

Morning report can also drive performance improvement(PI) by serving as a multidisciplinary forum to discusspatient care. Multidisciplinary teams have been shown toimprove outcomes for a number of surgical diseases.3336

Thus, including nurses, occupational and physical thera-pists, nutritionists, pharmacists, social workers, case man-agers, a PI manager, or consultant services in morningreport may reap similar benefits for ACS programs. Al-though such broad teams undoubtedly require significantlymore manpower and administrative organization, the bene-fits of a multidisciplinary approach potentially enhancemanagement of comorbid conditions, optimize dischargeplanning, and expedite rescue interventions when systemor process errors occur. However, we found that only 1 pro-gram had the institutional investment to conduct such amultidisciplinary morning report despite the potential costsavings. It is possible that as the health care system movesto more patient-centered care and accountable care organi-zations, this model will be increasingly embraced.

Including outpatient follow-up discussion in inpatient

651morning report offers yet another opportunity for systems

Case-based education has long been shown to result in3840

he Abetter retention of medical knowledge. Morning report,in its discussion of actual patients, is perhaps the ultimatemodel of case-based education. Trainees who are present-ing patients can hone their clinical thinking skills whilepolishing their presentation skills. Indeed, morning reporthas been cited previously as an opportunity for both patienthandoffs and trainee education.2,8 It has been described asan opportunity for residents to exercise and improve theirknowledge, leadership, presentation, and problem-solvingskills, with up to 88% of residents citing morning reportas an excellent educational experience.2,8 All of the centersin our study are teaching hospitals, and our respondentssupported the notion that morning report plays a key rolein resident education and developing clinical acumen.

There were some limitations to this qualitative study.Although we ensured diversity of respondents on the basisof geography and practice setting, our respondents cannotbe assumed to be fully representative of the universe ofACS programs in the United States, in particular thosewithout training programs. The interviews were conductedat a time when processes evolving at the sampled institu-tions; however, our findings are presented as if they werefixed in time. As with all qualitative research, our findingsare exploratory and hypothesis generating rather thanconclusive. Thus, we cannot prove, despite the opinionsgenerated and processes described, that morning report iscausally related to improved processes of care and out-comes for patients with injuries or NTSEs. Nevertheless,we feel that this work represents an important initial step inunderstanding the utility of morning report with the emer-gence of ACS.

Conclusions

Our exploratory analysis of centers with ACS programshas shown that morning report has the potential to serve asa multipurpose conference with a number of benefits,including continuity of patient care, systems-based PI,and resident education. Conducting such meetings rou-tinely, however, is not without challenges. Although morn-ing report improves continuity in the face of duty-hourlimitations and frequent personnel changes, the full benefitsmay not be harnessed because of the same time limitations,improvement. Although we have found little evidence ofthis practice in the literature, the benefits of outpatientdiscussion during inpatient morning report were exempli-fied by 1 program in our study.15 It is possible that thesediscussions could improve follow-up in the postdischargeperiod and hence reduce unintended readmissions forACS teams. In an era of escalating health care costs andmultiple efforts to reduce readmission rates for chronic dis-eases, morning report may be a tool for systems improve-ment. This may, in fact, be one model of establishing amedical home for a surgical patient population.37

652 Twhich preclude full attendance of incoming and outgoingWe are grateful to Drs Lee Hargraves, Timothy A.Emhoff, L.D. Britt, and George C. Velmahos for their inputon the initial interview template and to Dr Catarina I. Kiefefor her overall mentorship through all stages of this project.

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Appendix

Interview questions

Acute Care Surgery Specialty1. Do you consider Acute Care Surgery a specialty within

surgery?If not, ask the following:

1a. How do you consider it?2. How do you define Acute Care Surgery as a surgical

specialty?3. Describe the evolution of Acute Care Surgery as a spe-

cialty.Acute Care Surgery Team

8a. What is your operating room availability for non-traumatic surgical emergencies?

8b. What is your surgical ICU capacity?8c. Describe your ancillary and subspecialty support.

9. Is your institution a designated level 1 trauma center?If yes, ask the following:9a-yes. How, if at all, do you leverage resources fromthe trauma center infrastructure for Acute CareSurgery?

If no, ask the following:9a-no. If you had a Level I trauma center, how wouldyou imagine leveraging resources from the trauma

12.

Ac15.

654 The American Journal of Surgery, Vol 206, No 5, November 2013team provide care for?If trauma and non-trauma surgical emergencies are

grouped into a single team ask the following:5a-combined. What is the rationale for a combinedtrauma and emergency surgery team?

If trauma is a separate team from the team for non-trauma surgical emergencies ask:5a-separate. What is the rationale for separate teamsof trauma and non-trauma surgical emergencies?

Also ask the following:5b. What is your institutions approximate volume of

trauma cases and non-trauma surgical emergenciesannually using 2010 as a reference point?

6. Describe how your institutions Acute Care SurgeryTeam is structured?

If not answered above ask the following:6a. Who makes up the team?6b. What are their qualifications/credentials?6c. How many such individuals are there on the team?6d. What other responsibilities do they have?6e. Describe how residents function on the team.

7. How is call structured?Acute Care Surgery Infrastructure8. What are your institutional resources for caring for

Acute Care Surgery patients?If not answered above ask the following:4. How long has your institution had an Acute Care Sur-gery team?

5. What clinical problems does your Acute Care Surgery16. What kind of training should residents who also hopeto practice Acute Care Surgery have?

If not answered above ask the following:16a. Do you believe that Acute Care surgeons need

specialized fellowship training?17. If you could have unlimited resources for an

ideal Acute Care Surgery model, how would you de-sign it?

18. What do you think the future holds for Acute CareSurgery as a specialty?financially viable? How so?ute Care Surgery GeneralizationsWhy do you practice Acute Care Surgery?provide at the departmental level, at the institutionallevel and to the broader community that you serve?

If not answered above ask the following:12a. Approximately what proportion of your Acute

Care Surgery patients are referred from outlyinghospitals?

13. What do you think are the strengths and weaknessesof your Acute Care Surgery model?

14. Do you think that the Acute Care Surgery model ispartners across the institution?What benefits does your Acute Care Surgery modelcenter infrastructure for Acute Care Surgery?10. Do you collect data for your Acute Care Surgery pa-

tients? If so, how and why?Acute Care Surgery Model11. How do you facilitate communication in this model,

both within the team and between the team and its

Utilization of morning report by acute care surgery teams: results from a qualitative studyMethodsParticipantsInterviewsData analysis

ResultsStructure and content of morning reportAdvantages and disadvantages of morning reportAlternatives to morning report

CommentsConclusionsAcknowledgmentsReferencesAppendix Interview questionsAcute Care Surgery SpecialtyAcute Care Surgery TeamAcute Care Surgery InfrastructureAcute Care Surgery ModelAcute Care Surgery Generalizations