Beyond capacity: An EAST multicenter mixed-methods study exploring surgeon perceptions on patient ratios in acute care surgery
Authors
Danielle J. Wilson, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
Jaclyn A. Gellings, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
Jamie Coleman, Department of Surgery, University of Louisville, Louisville, Kentucky, USA.
Kaushik Mukherjee, Department of Surgery, Loma Linda University Health, Loma Linda, California, USA.
Stephanie Bonne, Advocate Health - MidwestFollow
Melissa Boltz, Department of Surgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA.
Jennifer L. Hartwell, Department of Surgery, The University of Kansas Medical Center, Kansas City, Kansas, USA.
Brandon Bruns, UT Southwestern Medical Center, Dallas, Texas, USA.
Jason Kurle, Detroit Medical Center, Detroit, Michigan, USA.
Moustafa Hassan, Department of Surgery, SUNY Upstate Medical University, Syracuse, New York, USA.
Samuel Rob Todd, Department of Trauma Surgery, Grady Health System, Atlanta, Georgia, USA.
Baila Maqbool, The University of New Mexico Department of Surgery, Albuquerque, New Mexico, USA.
Bryan C. Morse, Maine Medical Center, Portland, Maine, USA.
Michael W. Cripps, Advocate Health - Midwest
Mayur Patel, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Daniel R. Margulies, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.
Jordan T. Lilienstein, Department of Surgery, UCSF Fresno, Fresno, California, USA.
Negaar Aryan, Department of Surgery, University of California Irvine, Irvine, California, USA.
Ben L. Zarzaur, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA.
Charles V. Bayouth, Covenant Medical Center, Lubbock, Texas, USA.
John Porter, Department of Surgery, Cooper University Hospital, Camden, New Jersey, USA.
Kristan Staudenmayer, Department of Surgery, Stanford University, Stanford, California, USA.
Dalier R. Mederos, Broward Health Medical Center, Fort Lauderdale, Florida, USA.
Charles Fasanya, Department of Trauma, Good Samaritan University Hospital, West Islip, New York, USA.
Kyle Leneweaver, Department of Surgery, Ascension Sacred Heart Hospital Pensacola, Pensacola, Florida, USA.
Lewis E. Jacobson, Department of Surgery, Ascension St Vincent, Indianapolis, Indiana, USA.
Michael Steven Farrell, Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA.
Scott Norwood, Department of Surgery, The University of Texas Health Science Center at Tyler, Tyler, Texas, USA.
John David Cull, Surgery, Prisma Health Upstate, Greenville, South Carolina, USA.
Jason Hoth, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA.
Tovy Kamine, Department of Surgery, UMass Chan Medical School - Baystate Regional Campus, Springfield, Massachusetts, USA.
Recommended Citation
Wilson DJ, Gellings JA, Coleman J, et al. Beyond capacity: an EAST multicenter mixed-methods study exploring surgeon perceptions on patient ratios in acute care surgery. Trauma Surg Acute Care Open. 2025;10(4):e001937. Published 2025 Nov 13. doi:10.1136/tsaco-2025-001937
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.
Affiliations
Advocate Lutheran General Hospital