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Kinnear N, Jolly S, Herath M, Han J, Tran M, O'Callaghan M, Hennessey D, Dobbins C, Sammour T, Moore J. The acute surgical unit: An updated systematic review and meta-analysis. Int J Surg 2021; 94:106109. [PMID: 34536599 DOI: 10.1016/j.ijsu.2021.106109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/07/2021] [Accepted: 09/07/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To systematically review comparative studies on the acute surgical unit (ASU) model. METHODS Searches were performed of Cochrane, Embase, Medline and grey literature. Eligible articles were comparative studies of the Acute Surgical Unit (ASU) model published 01/01/2000-12/03/2020. Amongst patients with any diagnosis, primary outcomes were length of stay, after-hours operating, complications and cost. Secondary outcomes were time to surgical review, time to theatre, mortality and re-admission for patients with any diagnosis, and cholecystectomy during index admission for patients with biliary disease. Additional analyses were planned for specific cohorts, such as patients with appendicitis or cholecystitis. RESULTS Searches returned 9,677 results from which 77 eligible publications were identified, representing 150,981 unique patients. Cohorts were adequately homogenous for meta-analysis of all outcomes except cost. For patients with any diagnosis, compared with the Traditional model, the introduction of an ASU model was associated with reduced length of stay (mean difference [MD] 0.68 days; 95% confidence interval [CI] 0.38-0.98), after-hours operating rates (odds ratio [OR] 0.56; 95% CI 0.46-0.69) and complications (OR 0.48, 95% CI 0.33-0.70). Regarding cost, two studies reported savings following ASU introduction, while one found no difference. Amongst secondary outcomes, for patients with any diagnosis, ASU commencement was associated with reduced time to surgical review, time to theatre and mortality. Re-admissions were unchanged. For patients with biliary disease, ASU establishment was associated with superior rates of index cholecystectomy. CONCLUSION Compared to the Traditional structure, the ASU model is superior for most metrics. ASU introduction should be promoted in policy for widespread benefit.
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Affiliation(s)
- Ned Kinnear
- Adelaide Medical School, University of Adelaide, Adelaide, Australia Dept of Surgery, Royal Adelaide, Hospital, Adelaide, Australia Urology Unit, Flinders Medical Centre, Bedford Park, SA, Australia Flinders University, Adelaide, Australia Dept of Urology, Mercy University Hospital, Cork, Ireland
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Kinnear N, Herath M, Jolly S, Han J, Tran M, Parker D, O'Callaghan M, Hennessey D, Dobbins C, Sammour T, Moore J. Patient Satisfaction in Emergency General Surgery: A Prospective Cross-Sectional Study. World J Surg 2021; 44:2950-2958. [PMID: 32399656 DOI: 10.1007/s00268-020-05561-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The importance of the patient experience is increasingly being recognised. However, there is a dearth of studies regarding factors affecting patient-reported outcomes in emergency general surgery (EGS), including none from the Southern Hemisphere. We aim to prospectively assess factors associated with patient satisfaction in this setting. METHODS In this prospective cross-sectional study, all consecutive adult patients admitted to an acute surgical unit over four weeks were invited to complete a validated Patient-Reported Experience Measures questionnaire. These were completed either in person when discharge was imminent or by telephone <4 weeks post-discharge. Responses were used to determine factors associated with overall patient satisfaction. RESULTS From 146 eligible patients, 100 (68%) completed the questionnaire, with a mean overall satisfaction score of 8.3/10. On multivariate analyses, eight factors were significantly associated with increased overall satisfaction. Five of these were similar to those previously prescribed by other like studies, being patient age >50 years, sufficient analgesia, satisfaction with the level of senior medical staff, important questions answered by nurses and confidence in decisions made about treatment. Three identified factors were new: sufficient privacy in the emergency department, sufficient notice prior to discharge and feeling well looked after in hospital. CONCLUSIONS Factors associated with patient satisfaction were identified at multiple points of the patient journey. While some of these have been reported in similar studies, most differed. Hospitals should assess factors valued by their EGS population prior to implementing initiatives to improve patient satisfaction.
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Affiliation(s)
- Ned Kinnear
- Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia.
| | - Matheesha Herath
- Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Samantha Jolly
- Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Jennie Han
- Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Minh Tran
- Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Dominic Parker
- Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Michael O'Callaghan
- Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia.,South Australian Prostate Cancer Clinical Outcomes Collaborative, Urology Unit, Flinders Medical Centre, Adelaide, Australia.,Flinders Centre for Innovation in Cancer, Adelaide, Australia
| | - Derek Hennessey
- Department of Urology, Mercy University Hospital, Cork, Ireland
| | | | - Tarik Sammour
- Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia.,Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - James Moore
- Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia.,Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
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Kinnear N, Tran M, Han J, Jolly S, Herath M, Hennessey D, Dobbins C, Sammour T, Moore J. Does emergency general surgery model affect staff satisfaction, training and working hours? ANZ J Surg 2019; 90:262-267. [DOI: 10.1111/ans.15628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/15/2019] [Accepted: 11/16/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Ned Kinnear
- Discipline of Surgery, Faculty of Medical and Health Sciences, Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Minh Tran
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Jennie Han
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Samantha Jolly
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Matheesha Herath
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | | | - Christopher Dobbins
- Discipline of Surgery, Faculty of Medical and Health Sciences, Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
| | - Tarik Sammour
- Discipline of Surgery, Faculty of Medical and Health Sciences, Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - James Moore
- Discipline of Surgery, Faculty of Medical and Health Sciences, Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
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Degirolamo K, Murphy PB, D'Souza K, Zhang JX, Parry N, Haut E, Robert Leeper W, Leslie K, Vogt KN, Hameed SM. Processes of Health Care Delivery, Education, and Provider Satisfaction in Acute Care Surgery: A Systematic Review. Am Surg 2017. [DOI: 10.1177/000313481708301233] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In recent years, significant workload, high acuity, and complexity of emergency general surgery conditions have led hospitals to replace the traditional on-call model with dedicated acute care surgery (ACS) service models. A systematic search of Ovid, EMBASE, and MEDLINE was undertaken to examine the impact of ACS services on health-care delivery processes and cost, education, and provider satisfaction. From 1827 papers, reviewers identified 22 studies that met inclusion criteria and subsequently used The Evidence-Based Practice for Improving Quality method and Newcastle–Ottawa Scale to score quality and level of evidence. Most studies found an increase in daytime operating, improved patient transit from emergency department to operating room to home, and decreased length of stay. Higher and more diverse case volumes improved resident education and operative experience. ACS services enhanced the educational experience of residents on subspecialty services by offloading emergency work from those services. Finally, surgeons generally felt that ACS services improved job satisfaction, productivity, and billing. The ACS model has demonstrated improvement in timeliness of care, diversified case mix, decreased costs, improved trainee learning, and increased surgeon job satisfaction.
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Affiliation(s)
- Kristin Degirolamo
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick B. Murphy
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Karan D'Souza
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacques X. Zhang
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neil Parry
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
- Trauma Program, London Health Sciences Centre, London, Ontario, Canada
- Division of Critical Care, London Health Sciences Centre, London, Ontario, Canada
| | - Elliott Haut
- Division of Trauma and Acute Care Surgery, Johns Hopkins University, Baltimore, Maryland; and
| | - W. Robert Leeper
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
- Trauma Program, London Health Sciences Centre, London, Ontario, Canada
- Division of Critical Care, London Health Sciences Centre, London, Ontario, Canada
| | - Ken Leslie
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Kelly N. Vogt
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - S. Morad Hameed
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Blay N, Roche MA, Duffield C, Gallagher R. Intrahospital transfers and the impact on nursing workload. J Clin Nurs 2017; 26:4822-4829. [PMID: 28382638 DOI: 10.1111/jocn.13838] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2017] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To determine the rate of patient moves and the impact on nurses' time. BACKGROUND Bed shortages and strategies designed to increase patient flow have led to a global increase in patient transfers between wards. The impact of transferring patients between wards and between beds within a ward on nurses' workload has not previously been measured. DESIGN A two-stage sequential study. Retrospective analysis of hospital data and a prospective observational-timing study. METHODS Secondary analysis of an administrative data set to inform the rate of ward and bed transfers (n = 34,715) was undertaken followed by an observational-timing study of nurses' activities associated with patient transfers (n = 75). RESULTS Over 10,000 patients were moved 34,715 times in 1 year which equates to an average of 2.4 transfers per patient. On average, patient transfers took 42 min and bed transfers took 11 min of nurses' time. Based on the frequency of patient moves, 11.3 full-time equivalent nurses are needed to move patients within the site hospital each month. CONCLUSION Transferring patients is workload intensive on nurses' time and should be included in nursing workload measurement systems. RELEVANCE TO CLINICAL PRACTICE Nurses at the site hospital spend over 1700 hr each month on activities associated with transferring patients, meaning that less time is available for nursing care.
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Affiliation(s)
- Nicole Blay
- Centre for Health Services Management, Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.,Western Sydney University, Parramatta, NSW, Australia
| | - Michael A Roche
- Centre for Health Services Management, Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.,Mental Health Drug and Alcohol Nursing, Northern Sydney Local Health District, North Ryde, NSW, Australia.,School of Nursing, Midwifery & Paramedicine, Australian Catholic University, North Sydney, NSW, Australia
| | - Christine Duffield
- Centre for Health Services Management, Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.,Nursing and Health Services Management, Edith Cowen University, Joondalup, WA, Australia
| | - Robyn Gallagher
- Charles Perkins Centre, Sydney Nursing School, University of Sydney, Camperdown, NSW, Australia
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Søreide K. Emergency surgery over 111 years: are we still at a crossroads or ready for emergency surgery 2.0? Scand J Trauma Resusc Emerg Med 2015; 23:107. [PMID: 26689822 PMCID: PMC4687313 DOI: 10.1186/s13049-015-0189-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/09/2015] [Indexed: 01/28/2023] Open
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, N-4068, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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Surgeon accountability for patient safety in the Acute Care Surgery paradigm: a critical appraisal and need of having a focused knowledge of the patient and a specific subspecialty experience. Patient Saf Surg 2015; 9:38. [PMID: 26568771 PMCID: PMC4644281 DOI: 10.1186/s13037-015-0084-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/08/2015] [Indexed: 11/10/2022] Open
Abstract
There is an increasing evidence in the literature showing that Acute Care surgical patients, likewise patients from every other surgical subspeciality, should be best first approached and managed only by attending surgeons with approriate expertise in the field of Emergency and Trauma Surgery, as well as the occurrence of postoperative complications can be prevented or safely and appropriately treated when arising, only by those attending surgeons having a focused knowledge of the patient and specific subspeciality experience. The advantages of a consultant-led, patient-centered surgical management come along with the opportunity of maintaining the principles of continuity of care and specificity of expertise in managing surgical patients and their complications and readmissions. These principles should be particularly valid in the well-recognized subspeciality of Acute Care and Trauma Surgery; managing the challenging emergency surgical patients either in the preoperative and postoperative periods with the aim to improve the outcomes of Emergency Surgery, should only be by surgeons trained and experienced in both Acute Care Surgery and Trauma.
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Shakerian R, Thomson BN, Gorelik A, Hayes IP, Skandarajah AR. Outcomes in emergency general surgery following the introduction of a consultant-led unit. Br J Surg 2015; 102:1726-32. [PMID: 26492418 DOI: 10.1002/bjs.9954] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/05/2015] [Accepted: 08/27/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients presenting with emergency surgical conditions place significant demands on healthcare services globally. The need to improve emergency surgical care has led to establishment of consultant-led emergency surgery units. The aim of this study was to determine the effect of a changed model of service on outcomes. METHODS A retrospective observational study of all consecutive emergency general surgical admissions in 2009-2012 was performed. A 2-year time frame before and after the establishment of the emergency general surgery (EGS) service was used to determine the number of admissions and operations, emergency department and hospital length of stay, as well as complication rates. RESULTS The study included 7233 acute admissions. The EGS service managed 4468 patients (61·6 per cent increase) and performed 1804 operations (41·0 per cent increase). The most common diagnoses during the EGS period included acute appendicitis (532, 11·9 per cent), biliary disease (361, 8·1 per cent) and abdominal pain (561, 12·6 per cent). Appendicectomy (536, 29·7 per cent), cholecystectomy (239, 13·2 per cent) and laparotomy (226, 12·5 per cent) were the most commonly performed procedures. In the EGS period, time in the emergency department was reduced (from 8·0 to 6·0 h; P < 0·001), as was length of hospital stay (from 3·0 to 2·0 days; P < 0·001). The number of complications was reduced by 46·8 per cent, from 172 (6·2 per cent) to 147 (3·3 per cent) (P < 0·001), with a 53 per cent reduction in the number of deaths in the EGS period, from 29 (16·9 per cent) to seven (8 per cent) (P = 0·039). CONCLUSION The establishment of a consultant-led emergency surgical service has been associated with improved provision of care, resulting in timely management and improved clinical outcomes.
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Affiliation(s)
- R Shakerian
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - B N Thomson
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - A Gorelik
- Melbourne EpiCentre, Centre for Clinical Epidemiology, Biostatistics and Health Services Research, (University of Melbourne and Melbourne Health), The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - I P Hayes
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - A R Skandarajah
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
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Scott AJ, Mason SE, Arunakirinathan M, Reissis Y, Kinross JM, Smith JJ. Risk stratification by the Appendicitis Inflammatory Response score to guide decision-making in patients with suspected appendicitis. Br J Surg 2015; 102:563-72. [PMID: 25727811 DOI: 10.1002/bjs.9773] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/28/2014] [Accepted: 12/12/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Current management of suspected appendicitis is hampered by the overadmission of patients with non-specific abdominal pain and a significant negative exploration rate. The potential benefits of risk stratification by the Appendicitis Inflammatory Response (AIR) score to guide clinical decision-making were assessed. METHODS During this 50-week prospective observational study at one institution, the AIR score was calculated for all patients admitted with suspected appendicitis. Appendicitis was diagnosed by histological examination, and patients were classified as having non-appendicitis pain if histological findings were negative or surgery was not performed. The diagnostic performance of the AIR score and the potential for risk stratification to reduce admissions, optimize imaging and prevent unnecessary explorations were quantified. RESULTS A total of 464 patients were included, of whom 210 (63·3 per cent) with non-appendicitis pain were correctly classified as low risk. However, 13 low-risk patients had appendicitis. Low-risk patients accounted for 48·1 per cent of admissions (223 of 464), 57 per cent of negative explorations (48 of 84) and 50·7 per cent of imaging requests (149 of 294). An AIR score of 5 or more (intermediate and high risk) had high sensitivity for all severities of appendicitis (90 per cent) and also for advanced appendicitis (98 per cent). An AIR score of 9 or more (high risk) was very specific (97 per cent) for appendicitis, and the majority of patients with appendicitis in the high-risk group (21 of 30, 70 per cent) had perforation or gangrene. Ultrasound imaging could not exclude appendicitis in low-risk patients (negative likelihood ratio (LR) 1·0) but could rule-in the diagnosis in intermediate-risk patients (positive LR 10·2). CT could exclude appendicitis in low-risk patients (negative LR 0·0) and rule-in appendicitis in the intermediate group (positive LR 10·9). CONCLUSION Risk stratification of patients with suspected appendicitis by the AIR score could guide decision-making to reduce admissions, optimize utility of diagnostic imaging and prevent negative explorations.
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Affiliation(s)
- A J Scott
- Academic Surgical Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
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