Patrick B. Murphy

BACKGROUND: Interpersonal violence is one of the leading causes of death and disability. Hospital-based violence intervention programs (HVIPs) have been employed to address the psychosocial, educational, mental health, and other needs of injured patients. The objective of this systematic review and meta-analysis was to evaluate the impact of HVIPs in the United States or Canada on violent injury recidivism. METHODS: US or Canadian studies with clearly defined adult-only or adult-and-pediatric patient populations were analyzed to evaluate the efficacy of HVIPs (intervention) compared with no HVIPs (comparator) in preventing violent reinjury recidivism (outcomes). A systematic literature search and review was conducted, and the quality of evidence was evaluated per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. We performed a meta-analysis with leave-one-out sensitivity analysis of studies meeting criteria for quantitative assessment. RESULTS: Seventeen studies met our selection criteria and were included in the qualitative analysis, including one subgroup study. Of these, 10 studies were included in a meta-analysis, with results favoring HVIP programs (OR, 0.60; 95% CI, 0.38–0.94; Cochran’s Q p =0.0025) for the prevention of violent injury recidivism. Overall evidence quality was deemed to be low, with substantial heterogeneity (I² = 64.7%) between studies. CONCLUSIONS: We conditionally recommend HVIP programs in urban trauma centers with substantive violent injury in adult-only or mixed adult-pediatric populations in the United States or Canada for the prevention of violent injury recidivism, with centers evaluating program design and benefit locally. Given the heterogeneity of reported results and program offerings, we also recommend continuing research on this topic, with the creation of a standard definition of HVIP programs and outcomes of interest. ( J Trauma Acute Care Surg 2026;00:000–000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.) LEVEL OF EVIDENCE: Systematic Review with Meta-Analysis; Level IV.

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Emergency general surgery (EGS) represents a significant portion of admissions to hospitals and overall surgical care delivery, yet comprehensive outcome tracking and quality improvement efforts have lagged behind elective surgery and trauma care. This article outlines the gap in data and provides three practical solutions to registry development: third-party registry software with dedicated registrars, leveraging existing National Surgical Quality Improvement Program (NSQIP) infrastructure through the EGS-NSQIP module, and automated data extraction from electronic medical records. Each approach offers unique advantages in addressing the dual challenges of case identification and risk-adjusted outcome measurement for both local quality improvement and national benchmarking. The aim of this white paper is to provide pragmatic, scalable data solutions for EGS leaders seeking to implement contemporary quality improvement and verification efforts.

Recent multicenter studies have explored the current and desired clinical work for acute care surgeons. Acute care surgeons oversee and provide comprehensive care in trauma, surgical critical care, emergency general surgery, and burn patients. While these studies provide crucial data to guide planning at individual institutions to help address understaffed programs, translating this research into local practice and culture requires nuance and consideration of system (regional, institutional, department, and divisional) factors and individual surgeon goals. This opinion piece confronts the paradox at the heart of academic acute care surgery: how can surgeons deliver on educational and research missions when staffing models place the highest prioritization on clinical work? We present a practical, evidence-based framework that aligns sustainable clinical staffing with preservation of the tripartite academic mission in acute care surgery. LEVEL OF EVIDENCE: Level V.

Reducing disparities and achieving health equity are critical goals for the trauma community. Although significant advances have been made in short-term trauma outcomes, disparities persist across various dimensions including race, sex, gender, socioeconomic status, and geographic location. This manuscript represents a distillation of a panel discussion from the 2024 Western Trauma Association meeting that examined three under-recognized categories of trauma disparities beyond traditional demographic factors. First, sex-related disparities in motor vehicle crashes stem from crash test dummies designed primarily for male physiology. Second, financial toxicity and exploring the relationship between acute trauma, financial hardship, and long-term mental and physical quality of life. Third, geographic disparities create “trauma deserts” where disadvantaged populations experience prolonged transport times and reduced access to life-saving care. The panel explored opportunities within each to improve patient outcomes at the local, regional, and national levels. ( J Trauma Acute Care Surg. 2026;00:000–000. Copyright© 2026 Wolters Kluwer Health, Inc. All rights reserved.)

Acute care surgery (ACS) is a specialty that includes trauma, emergency general surgery, and surgical critical care. It has become a vital surgical specialty in the United States, providing surgical services, rescue functions, disaster response, and other important services. Despite its key role in patient care and hospital operations, ACS faces challenges to its sustainability. This overview targets readers who wish to understand the structure and scope of ACS and who work with or manage these practices. The goal is to provide an overview of ACS, its current challenges, and suggestions for developing the specialty. This consensus statement was created by the Acute Care Surgery Workforce Workgroup, which includes representatives from various national surgical organizations. The article combines current ACS models, staffing and compensation practices, and institutional value. It relies on expert agreements and national trends. Several key themes are examined. The value of ACS is shown through better patient outcomes, efficiency, cost savings, and support for institutional missions like disaster preparedness and education. Current ACS programs differ significantly in structure, but two main staffing models exist: traditional (historic) and time delineated. Each model has its own advantages and challenges regarding workload, sustainability, and academic involvement. Regardless of the staffing model, most physician compensation often depends on the measurement of work relative value units. However, these do not fully capture the extent and intensity of ACS work. Additional challenges for the specialty include inconsistencies in terminologies, the absence of board certification, and varying compensation standards. Acute care surgery is a crucial specialty that provides significant value to patients, hospitals, and health care systems. To maintain sustainability and quality, health care leaders need to consider the complexities of ACS practice discussed in this article as well as local demands. Staffing and compensation models should be sustainable and optimize for patient care. Recognizing both clinical and nonclinical contributions of ACS surgeons is essential for resilience and further development of the specialty.

Background: Best practice guidelines from trauma-focused organizations support early (<72 hours) venous thromboembolism (VTE) chemoprophylaxis initiation in traumatic brain injury (TBI) patients. Recent literature suggests that an even more aggressive initiation (24 hours) is safe and efficacious. It is unknown how current practice aligns with the existing literature and best practice guidelines. We performed a national survey to characterize variation in trauma surgeons’ reported practices and attitudes regarding VTE chemoprophylaxis initiation in TBI patients with the hypothesis that they will vary widely. Methods: All 1700 American Association for the Surgery of Trauma members were surveyed online. Members who routinely cared for patients with TBI were asked to proceed with the survey. Descriptive data were reported. The questions characterized institutional guidelines, and if none existed, individual practice patterns regarding goal timeline of VTE chemoprophylaxis in TBI patients. Results: 374 members (22%) completed the survey. Most respondents worked at academic institutions (40%) and represented a level one trauma center (44%). Enoxaparin was the most common VTE chemoprophylactic (73%) with most using weight-based dosing (76%) and anti-Xa testing (75%). Institutional policies that included a protocol for VTE chemoprophylaxis initiation in TBI patients were used by 86% of respondents. In those with established protocols, 59% reported being mostly compliant. Reasons for delay of VTE chemoprophylaxis included worry about progression of TBI and disagreement with consulting services. 293 (80%) of respondents reported protocolized repeat head CT within 4–12 hours after initial CT (60%). In response to a clinical scenario, 43% of respondents reported that their goal timeline for initiating VTE prophylaxis was within 24 hours of a stable head CT. Conclusions: Despite national guidelines, substantial variation remains in the timing of VTE chemoprophylaxis in TBI patients. Passive strategies, such as institutional guidelines alone, are insufficient. Institutions must adopt more effective implementation tactics—including protocol-enforced order sets, automated clinical decision support, and shared governance models with ancillary services—to ensure timely, evidence-based care. Level of evidence: Level V.

Background: Optimal provider-to-patient (PtP) ratios in acute care surgery (ACS) remain undefined despite their importance for care quality and provider sustainability. This study aimed to understand surgeon perspectives on maximum ideal ratios across trauma, emergency general surgery (EGS) and surgical intensive care unit (SICU) services. Methods: This multicenter mixed-methods study combined quantitative surveys and semistructured interviews with ACS surgeons at level I/II trauma centers across the USA (1 August 2023–19 April 2024). Service line census data were also collected. Interviews were recorded, transcribed and qualitative analysis performed; surveys were analyzed with descriptive statistics. Results: Fifty-two interviews were completed. Survey response rate was 50.3% (212/421 eligible division leadership and faculty) from 40 centers across 24 states. The perceived maximum safe patient load for trauma and EGS was <20 patients when working independently, and up to 40 patients with full team support. SICU ratios were lower with most reporting ≤10 patients for independent coverage and ≤20 with team support. Regarding appropriate patient loads for junior residents and advanced practice providers, most respondents recommended ≤10 patients for trauma/EGS and ≤7 for SICU. For senior residents, most recommended ≤13 patients for trauma/EGS and ≤7 for SICU. Notably, 72% of centers exceeded their own leadership-recommended maximums for at least one service line. Qualitative analysis revealed patient acuity, team experience and competing demands as key workload modulators, with concerns about care quality degradation and burnout at higher ratios. Conclusions: This study establishes potential upper threshold benchmarks for ACS PtP ratios with strong agreement across institutions. Division leadership should consider developing staffing models that account for patient acuity and service complexity while implementing escalation protocols for sustained high workloads. Current practices frequently exceed maximum ideal ratios, highlighting the need for evidence-based staffing guidelines that balance financial constraints with mounting evidence linking workload intensity and density to adverse outcomes. Level of evidence: IV.