Beyond capacity: an EAST multicenter mixed-methods study exploring surgeon perceptions on patient ratios in acute care surgery
Author Department
Surgery
Document Type
Article, Peer-reviewed
Publication Date
11-2025
Abstract
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.
Keywords: Delivery of Health Care; Practice Patterns, Physicians'; quality improvement; workload.
Recommended Citation
Wilson DJ, Gellings JA, Coleman J, Mukherjee K, Bonne S, Boltz M, Hartwell JL, Bruns B, Kurle J, Hassan M, Todd SR, Maqbool B, Morse BC, Cripps MW, Patel M, Margulies DR, Lilienstein JT, Aryan N, Zarzaur BL, Bayouth CV, Porter J, Staudenmayer K, Mederos DR, Fasanya C, Leneweaver K, Jacobson LE, Farrell MS, Norwood S, Cull JD, Hoth J, Kamine T, Prabhakaran K, Rakitin I, Englehart MS, Fusco-Ruiz T, Blondeau B, Adams CA Jr, McKenzie K, Holleman G, Liggett MR, Cunningham K, DeMoya M, Murphy PB; ACS Staffing Authorship Group. Beyond capacity: an EAST multicenter mixed-methods study exploring surgeon perceptions on patient ratios in acute care surgery. Trauma Surg Acute Care Open. 2025 Nov 13;10(4):e001937. doi: 10.1136/tsaco-2025-001937.
PMID
41262852