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Tian BW. The rise of ACS and its importance. World J Emerg Surg 2024; 19:9. [PMID: 38459488 PMCID: PMC10921708 DOI: 10.1186/s13017-024-00538-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 03/10/2024] Open
Affiliation(s)
- Brian Wca Tian
- Department of General Surgery, Singapore General Hospital, Outram Road, Singapore, S169608, Singapore.
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2
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Anand E, Rahman SA, Tomlinson C, Mercer SJ, Pucher PH. Comparison of major abdominal emergency surgery outcomes across organizational models of emergency surgical care: Analysis of the UK NELA national database. J Trauma Acute Care Surg 2024; 96:305-312. [PMID: 37381144 DOI: 10.1097/ta.0000000000004056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Emergency general surgery (EGS) admissions account for a large proportion of surgical care and represent the majority of surgical patients who suffer in-hospital mortality. Health care systems continue to experience growing demand for emergency services: one way in which this is being increasingly addressed is dedicated subspecialty teams for emergency surgical admissions, most commonly termed "emergency general surgery" in the United Kingdom. This study aims to understand the impact of the emergency general surgery model of care on outcomes from emergency laparotomies. METHODS Data was obtained from the National Emergency Laparotomy Audit database. Patients were dichotomized into EGS hospital or non-EGS hospital. Emergency general surgery hospital is defined as a hospital where >50% of in-hours emergency laparotomy operating is performed by an emergency general surgeon. The primary outcome was in-hospital mortality. Secondary outcomes were intensive therapy unit (ITU) length of stay and duration of hospital stay. A propensity score weighting approach was used to reduce confounding and selection bias. RESULTS There were 115,509 patients from 175 hospitals included in the final analysis. The EGS hospital care group included 5,789 patients versus 109,720 patients in the non-EGS group. Following propensity score weighting, mean standardized mean difference reduced from 0.055 to <0.001. In-hospital mortality was similar (10.8% vs. 11.1%, p = 0.094), with mean length of stay (16.7 days vs. 16.1 days, p < 0.001) and ITU stay (2.8 days vs. 2.6 days, p < 0.001) persistently longer in patients treated in EGS systems. CONCLUSION No significant association between the emergency surgery hospital model of care and in-hospital mortality in emergency laparotomy patients was seen. There is a significant association between the emergency surgery hospital model of care and an increased length of ITU stay and overall hospital stay. Further studies are required to examine the impact of changing models of EGS delivery in the United Kingdom. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Easan Anand
- From the Department of Surgery (E.A., S.A.R.), University Hospital Southampton, Southampton; Institute of Health Informatics (C.T.), University College London, London; Department of Surgery (S.J.M., P.H.P.), Portsmouth Hospitals University NHS Trust; School of Pharmacy and Biosciences (P.H.P.), University of Portsmouth, Portsmouth; and Division of Surgery (P.H.P.), Imperial College London, London, United Kingdom
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Quaile O, Perrodin SF, Trippel A, Schnüriger B. Characteristics of emergency general surgery services in Switzerland: a nationwide survey. Eur J Trauma Emerg Surg 2024; 50:259-268. [PMID: 37470790 PMCID: PMC10923733 DOI: 10.1007/s00068-023-02272-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/14/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Running an emergency general surgery (EGS) service is challenging and requires significant personnel and institutional resources. The aim of this study was to achieve a nationwide overview of the individual EGS service organizations in public hospitals in Switzerland. METHODS All Swiss public hospitals with a surgical and emergency department were included and contacted by telephone. General surgeons were interviewed between December 2021 and January 2022 using a standardized questionnaire. RESULTS Seventy-two out of 79 public hospitals in Switzerland (91.1%) agreed to the survey. They employed 1,581 surgeons in 19 (26.4%) hospitals with < 100 beds, 39 (54.2%) hospitals with 100-300 beds, 7 (9.7%) with 300-600 beds, and 7 (9.7%) with > 600 beds. The median number of surgeons per hospital was 20.5 (IQR 13.0-29.0). Higher level of care (intermediate or intensive care unit) was significantly less available in small hospitals (< 100 beds). The median hour of designated emergency operating room capacity per day was 14 h (IQR 14-24) for all hospitals with < 600 beds and 24 h (IQR 14-24) for the largest hospitals (> 600 beds). With increasing hospital size, there was a significant increase in the number of surgical units where EGS and orthopedic trauma surgery were covered by two separate teams (21.1% vs. 43.6% vs. 85.7% vs. 100%, p = 0.035). The median number of surgeons on-call per hospital and per 24 h was 5.0 (IQR 3.3-6.0). CONCLUSION Lack of higher level of care in small hospitals, limited emergency OR capacity and short rotations of on-call teams are major drawbacks of many current EGS systems in Switzerland. Centralization of critically ill EGS patients and reorganization of surgical on-call systems to designated acute care surgery teams should be considered.
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Affiliation(s)
- Oliver Quaile
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stéphanie Fabienne Perrodin
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Amedeo Trippel
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Anheuser P, Michels G, Gakis G, Neisius A, Steffens J, Kranz J. [Position paper of the working group Urological Acute Medicine]. UROLOGIE (HEIDELBERG, GERMANY) 2023; 62:936-940. [PMID: 37115300 DOI: 10.1007/s00120-023-02090-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 04/29/2023]
Abstract
Emergency patients with acute genitourinary system diseases are frequently encountered in both outpatient and clinical emergency structures. It is estimated that one-third of all inpatients in a urology clinic initially present as an emergency. In addition to general emergency medicine knowledge, specialized urologic expertise is a prerequisite for the care of these patients, which is needed early and specifically for optimal treatment outcomes. It must be taken into account that, on the one hand, the current structures of emergency care still lead to delays in patient care despite positive developments in recent years. On the other hand, most hospital emergency facilities need urologic expertise on site. In addition, politically intended changes in our health care system, which drive an increasing ambulantization of medicine and condition a further centralization of emergency clinics, become effective. The aim of the newly established working group "Urological Acute Medicine" is to ensure and further improve the quality of care for emergency patients with acute genitourinary system diseases and, in consensus with the German Society of Interdisciplinary Emergency and Acute Medicine, to define precise task distributions and interfaces of both specialities.
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Affiliation(s)
- Petra Anheuser
- Klinik für Urologie, Asklepios Klinik Wandsbek, Alphonsstr. 14, 22403, Hamburg, Deutschland.
- Universitätsklinik und Poliklinik für Urologie, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland.
| | - Guido Michels
- Klinik für Akut- und Notfallmedizin, St. Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Georgios Gakis
- Universitätsklinik und Poliklinik für Urologie, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Andreas Neisius
- Abteilung für Urologie und Kinderurologie, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Trier, Deutschland
| | - Joachim Steffens
- Klinik für Urologie und Kinderurologie, St. Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Jennifer Kranz
- Universitätsklinik und Poliklinik für Urologie, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
- Klinik für Urologie und Kinderurologie, Uniklinik RWTH Aachen, Aachen, Deutschland
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Chan E, Izwan S, Ng J, Swindon D, Teng R, Wong KSC, Cooper M. Time to acute general surgical review: a retrospective study in a tertiary referral centre. ANZ J Surg 2023. [PMID: 37147896 DOI: 10.1111/ans.18476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/22/2023] [Accepted: 04/09/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND The Acute Surgical Unit (ASU) is a busy service receiving Emergency Department (ED) referrals for adult and paediatric general surgery care alongside trauma. The ASU model deviates from the traditional on-call model and has been shown to improve efficiency and patient outcomes. The primary aim was to evaluate time to surgical review ED presentation and general surgical referral. Secondary aims were to assess referral numbers, pathology and demographics at our institution. METHODS A retrospective observational analysis was conducted on all referral times from the ED to the ASU between 1 April and 30 September 2022. Patient demographics, triage and referral times, and diagnoses were collected from the electronic medical record. Time between referral, review and surgical admission were calculated. RESULTS A total of 2044 referrals were collected during the study period, and 1951 (95.45%) were included for analysis. Average time from ED presentation to surgical referral was 4 hours and 54 min with average time to surgical review from referral taking 40 min. On average, total time from ED presentation to surgical admission was 5 h and 34 min. Trauma Responds took 6 min to review. Colorectal pathology was the most commonly referred disease type. CONCLUSION The ASU model is efficient and effective within our health service. Overall delays in surgical care may be external to the general surgery unit, or before the patient is made known to the surgical team. Analysis of time to surgical review is a key statistic in the delivery of acute surgical care.
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Affiliation(s)
- Erick Chan
- Department of General Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Sara Izwan
- Department of General Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Justin Ng
- Department of General Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Daisy Swindon
- Department of General Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Roy Teng
- Department of General Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Kok Sum Chloe Wong
- Department of General Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Michelle Cooper
- Department of General Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Lepercq D, Gauss T, Godier A, Bellet J, Bouhours G, Bouzat P, Cailliau E, Cook F, David JS, Drame F, Gauthier M, Lamblin A, Pottecher J, Tavernier B, Garrigue-Huet D. Association of Organizational Pathways With the Delay of Emergency Surgery. JAMA Netw Open 2023; 6:e238145. [PMID: 37052916 PMCID: PMC10102875 DOI: 10.1001/jamanetworkopen.2023.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/24/2023] [Indexed: 04/14/2023] Open
Abstract
Importance Delayed admission of patients with surgical emergencies to the operating room occurs frequently and is associated with poor outcomes. In France, where 3 distinct organizational pathways in hospitals exist (a dedicated emergency operating room and team [DET], a dedicated operating room in a central operating theater [DOR], and no dedicated structure or team [NOR]), neither the incidence nor the influence of delayed urgent surgery is known, and no guidelines are available to date. Objective To examine the overall frequency of delayed admission of patients with surgical emergencies to the operating room across the 3 organizational pathways in hospitals in France. Design, Setting, and Participants This prospective multicenter cohort study was conducted in 10 French tertiary hospitals. All consecutive adult patients admitted for emergency surgery from October 5 to 16, 2020, were included and prospectively monitored. Patients requiring pediatric surgery, obstetrics, interventional radiology, or endoscopic procedures were excluded. Exposures Emergency surgery. Main Outcomes and Measures The main outcome was the global incidence of delayed emergency surgery across 3 predefined organizational pathways: DET, DOR, and NOR. The ratio between the actual time to surgery (observed duration between surgical indication and incision) and the ideal time to surgery (predefined optimal duration between surgical indication and incision according to the Non-Elective Surgery Triage classification) was calculated for each patient. Surgery was considered delayed when this ratio was greater than 1. Results A total of 1149 patients were included (mean [SD] age, 55 [21] years; 685 [59.9%] males): 649 in the DET group, 320 in the DOR group, and 171 in the NOR group (missing data: n = 5). The global frequency of surgical delay was 32.5% (95% CI, 29.8%-35.3%) and varied across the 3 organizational pathways: DET, 28.4% (95% CI, 24.8%-31.9%); DOR, 32.2% (95% CI, 27.0%-37.4%); and NOR, 49.1% (95% CI, 41.6%-56.7%) (P < .001). The adjusted odds ratio for delay was 1.80 (95% CI, 1.17-2.78) when comparing NOR with DET. Conclusions and Relevance In this cohort study, the frequency of delayed emergency surgery in France was 32.5%. Reduced delays were found in organizational pathways that included dedicated theaters and teams. These preliminary results may pave the way for comprehensive large-scale studies, from which results may potentially inform new guidelines for quicker and safer access to emergency surgery.
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Affiliation(s)
| | - Tobias Gauss
- Division of Anesthesia–Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Anne Godier
- Department of Anaesthesiology and Critical Care, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
- Université de Paris, Inserm, Innovations Thérapeutiques en Hémostase, Paris, France
| | - Julie Bellet
- Pôle d’anesthésie-réanimation, CHU de Lille, Lille, France
| | - Guillaume Bouhours
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Pierre Bouzat
- University of Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, Grenoble, France
| | | | - Fabrice Cook
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII School of Medicine, Creteil, France
| | - Jean-Stéphane David
- Service d’Anesthésie Réanimation, Groupe Hospitalier Sud, Hospices Civils de Lyon, Lyon, France
| | - Fatou Drame
- AP-HP, Beaujon University Hospital, DMU PARBOL, Department of Anaesthesiology and Critical Care, Clichy, France
| | - Marvin Gauthier
- Division of Anesthesia–Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Antoine Lamblin
- Anesthesiology and Critical Care Medicine Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Espace Ethique Méditerranéen, Efaculté de Médecine de Marseille, Timone University Hospital, Marseille, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Department of Anaesthesiology, Critical Care and Perioperative Medicine, Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg, ER 3072, Strasbourg, France
| | - Benoit Tavernier
- Pôle d’anesthésie-réanimation, CHU de Lille, Lille, France
- Université Lille, CHU Lille, ULR 2694–METRICS, Lille, France
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Dhanaskeara CS, Caballero B, Moolupuri A, Chung C, Puckett Y, Santos A, Estrada M, Alhaj Saleh A, Ronaghan CA, Dissanaike S, Richmond RE. Patient Outcomes in Laparoscopic Appendectomy With Acute Surgical Care Model Compared to Traditional Call. J Surg Res 2023; 281:282-288. [PMID: 36219940 DOI: 10.1016/j.jss.2022.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/16/2022] [Accepted: 08/15/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Shift-based models for acute surgical care (ACS), where surgical emergencies are treated by a dedicated team of surgeons working shifts, without a concurrent elective practice, are becoming more common nationwide. We compared the outcomes for appendectomy, one of the most common emergency surgical procedures, between the traditional (TRAD) call and ACS model at the same institution during the same time frame. METHODS A retrospective review of patients who underwent laparoscopic appendectomy for acute appendicitis during 2017-2018. ACS and TRAD-patient demographics, clinical presentation, operative details, and outcomes were compared using independent sample t-tests, Wilcoxon rank-sum tests and Fisher's exact or χ2 tests. Multiple exploratory regression models were constructed to examine the effects of confounding variables. RESULTS Demographics, clinical presentation, and complication rates were similar between groups except for a longer duration of symptoms prior to arrival in the TRAD group (Δ = 0.5 d, P = 0.006). Time from admission to operating room (Δ = -1.85 h, P = 0.003), length of hospital stay (Δ = -2.0 d, P < 0.001), and total cost (Δ = $ -2477.02, P < 0.001) were significantly lower in the ACS group compared to the TRAD group. Furthermore, perforation rates were lower in ACS (8.3% versus 28.6%, P = 0.003). Differences for the outcomes remained significant even after controlling for duration of symptoms prior to arrival (P < 0.05). CONCLUSIONS Acute appendicitis managed using the ACS shift-based model seems to be associated with reduced time to operation, hospital stay, and overall cost, with equivalent success rates, compared to TRAD.
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Affiliation(s)
| | - Beatrice Caballero
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Abhi Moolupuri
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Caroline Chung
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Yana Puckett
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Ariel Santos
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Michelle Estrada
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Adel Alhaj Saleh
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Catherine A Ronaghan
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Robyn E Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas.
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McGill M, Dhanasekara CS, Caballero B, Chung C, Alhaj-Saleh A, Santos A, Ronaghan C, Dissanaike S, Richmond R. Improved Outcomes in Treating Acute Biliary Disorders With a Shift-Based Acute Care Surgery Model. Am Surg 2022:31348221074229. [PMID: 35235754 DOI: 10.1177/00031348221074229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND As Acute Care Surgery and shift-based models increase in popularity, there is evidence of better outcomes for many types of emergency general surgery patients. We explored the difference in outcomes for patients with acute biliary disorders, treated by either Acute Care Surgery (ACS) model or traditional call model (TRAD) during the same period. METHODS Retrospective review of patients undergoing laparoscopic cholecystectomy for acute biliary disease 2017-2018. Demographics, clinical presentation, operative details, and outcomes were compared. RESULTS Demographics, clinical presentation, and complication rates were similar between groups. Time from surgical consult to operating room (Δ = -15.34 hours [-24.57, -6.12], P = .001), length of stay (Δ = -1.4 days [-2.45, -.35], P = .009), and total charges were significantly decreased in ACS group compared to TRAD (Δ$2797.76 [-4883.12, -712.41], P = .009). CONCLUSIONS Acute biliary disease can be managed successfully in an ACS shift-based model with reduced overall hospital charges and equivalent outcomes.
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Affiliation(s)
- Michelle McGill
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | | | - Beatrice Caballero
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Caroline Chung
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Adel Alhaj-Saleh
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Ariel Santos
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Catherine Ronaghan
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Robyn Richmond
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
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Bhat S, Varghese C, Xu W, Barazanchi AWH, Ratnayake B, O'Grady G, Windsor JA, Wells CI. Outcomes following out-of-hours acute cholecystectomy: A systematic review and meta-analysis. J Trauma Acute Care Surg 2022; 92:447-455. [PMID: 34554140 DOI: 10.1097/ta.0000000000003402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cholecystectomy is one of the most commonly performed abdominal operations. Rising demands on acute operating theater availability and resource utilization in the daytime have led to acute cholecystectomy being performed out-of-hours (in the evenings, at night, or on weekends), although it remains unknown whether outcomes differ between out-of-hours and in-hours (during the daytime on weekdays) acute cholecystectomy. This systematic review and meta-analysis aimed to compare outcomes following out-of-hours versus in-hours acute cholecystectomy. METHODS The study protocol was prospectively registered on PROSPERO (ID: CRD42021226127). MEDLINE, EMBASE, and Scopus databases were systematically searched for studies comparing outcomes following out-of-hours and in-hours acute cholecystectomy in adults with any acute benign gallbladder disease. The outcomes of interest were rates of bile leakage, bile duct injury, overall postoperative complications, conversion to open cholecystectomy, specific intraoperative and postoperative complications, length of stay, readmission, and mortality. Subgroup (evening/night-time vs. daytime, weekend vs. weekday, acute surgical unit [ASU]-only, non-ASU, and laparoscopic-only) and sensitivity analyses of adjusted multivariate regression analysis results was also performed. RESULTS Eleven studies were included. There were no differences between out-of-hours and in-hours acute cholecystectomy for rates of bile leakage, bile duct injury, overall postoperative complications, conversion to open cholecystectomy, operative duration, readmission, mortality, and postoperative length of stay. Higher rates of postoperative sepsis (odds ratio, 1.58; 95% confidence interval, 1.04-2.41; p = 0.03) and pneumonia (odds ratio, 1.55; 95% confidence interval, 1.06-2.26; p = 0.02) were observed following out-of-hours acute cholecystectomy on univariate meta-analysis, but not after the adjusted multivariate meta-analysis. Higher conversion rates were observed when out-of-hours cholecystectomy was performed in centers without an ASU. CONCLUSION This systematic review and meta-analysis has not shown an increased risk in overall or specific complications associated with out-of-hours compared with in-hours acute cholecystectomy. However, future studies should assess the potential impact of structural hospital factors, such as an ASU, on outcomes following out-of-hours acute cholecystectomy. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis Study, Level IV.
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Affiliation(s)
- Sameer Bhat
- From the Department of Surgery (S.B., C.V., W.X., A.W.H.B., B.R., G.O., J.A.W., C.I.W.), Faculty of Medical and Health Sciences, and Auckland Bioengineering Institute (G.O.), The University of Auckland, Auckland, New Zealand
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Marwaha JS, Drolet BC, Adams CA. The Impact of Concurrent Multi-Service Coverage on Quality and Safety in Trauma Care. J Surg Res 2022; 270:463-470. [PMID: 34800792 PMCID: PMC8712380 DOI: 10.1016/j.jss.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/25/2021] [Accepted: 10/10/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND At many trauma centers in the United States, one acute care surgeon is responsible for overnight coverage of both the emergency general surgery (EGS) and trauma services. The impact of this scheduling phenomenon on the quality and safety of trauma care has not been studied. METHODS Overnight (12:00 AM to 7:00 AM) trauma admissions to an academic Level 1 trauma center from 2013-2015 were studied after the institution adopted this scheduling phenomenon. Admissions were divided into two groups based on whether the admitting surgeon covered only the trauma service, or both the trauma and EGS services ("multi-service coverage"). Four major outcomes (e.g., mortality and complications), six quality metrics (e.g., time to first OR visit and unplanned transfers to the ICU), and procedural utilization patterns were compared. RESULTS A total of 1046 admissions were included. There were no differences in any major outcomes between the two exposure groups, including any National Trauma Data Bank-defined complication (OR 1.1, 95% CI 0.8-1.5, P= 0.5). Quality metrics dependent on the admitting surgeon remained unchanged, including attending presence at the highest-level trauma activations within 15 min of arrival (93% versus 86%, P= 0.07) and time to urgent operative intervention (68 min versus 82 min, P= 0.9). There were no differences in the number of laboratory and imaging studies (4.1 versus 4.1, P= 0.9) or bedside interventions (1.8 versus 2.1, P= 0.4) performed per patient by the admitting surgeon. Multivariate logistic regression did not identify multi-service coverage as an independent risk factor for adverse patient outcomes or quality metrics. CONCLUSIONS Trauma admissions under a surgeon covering multiple services simultaneously had similar outcomes, quality metrics, and procedural utilization patterns compared to trauma admissions under surgeons covering only the trauma service. Despite concerns that multiple-service coverage may overburden one acute care surgeon, time-dependent quality metrics and studies done during the initial workup of trauma patients remained unchanged. These findings suggest that simultaneous trauma and EGS service coverage by one acute care surgeon does not adversely impact trauma patient care.
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Affiliation(s)
- Jayson S Marwaha
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts.
| | - Brian C Drolet
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Charles A Adams
- Division of Trauma and Surgical Critical Care, Department of Surgery, Rhode Island Hospital, Providence, Rhode Island
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11
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Wong A, Burstow MJ, Yuide PJ, Naidu S, Lancashire RP, Chua TC. Comparative Analysis of Models of Care and Its Impact on Emergency Cholecystectomy Outcomes. J Laparoendosc Adv Surg Tech A 2022; 32:756-762. [PMID: 35041542 DOI: 10.1089/lap.2021.0588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Background: The implementation of the acute surgical unit (ASU) model has been demonstrated to improve care outcomes for the emergency general surgery patient in comparison to the traditional "on call" model. Currently, only few studies have evaluated surgical outcomes of the ASU model in patients with acute biliary pathologies. This is the first comparative study of two different emergency surgery structures in the acute management of patients with acute cholecystitis and biliary colic. Methods: A retrospective review of patients who underwent emergency cholecystectomy for acute cholecystitis and biliary colic at two tertiary hospitals between April 2018 and March 2019 was conducted. Primary outcomes included length of hospital stay, time from admission to definitive surgery, and postoperative complications. Secondary outcomes include proportion of cases performed during daylight hours, length of operating time, rate of conversion to open cholecystectomy, and consultant surgeon involvement. Results: A total of 339 patients presented with acute biliary symptoms and were managed operatively. Univariate analysis identified a shorter mean time to surgery in the traditional group compared to the ASU group (29.2 hours versus 43.1 hours; P < .001). There was no difference in mean length of stay, operation duration between models, and postoperative complication rates between groups, with the majority of surgeries performed during daylight hours. The ASU group had a greater proportion of consultant-led cases (48.2% versus 2.5%, P < .001) compared to the traditional group. Conclusion: Patients with acute biliary pathology requiring laparoscopic cholecystectomy achieve equivalent surgical outcomes irrespective of the model of acute surgical care.
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Affiliation(s)
- Alixandra Wong
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - Matthew J Burstow
- Department of Surgery, Logan Hospital, Meadowbrook, Australia.,School of Medicine, Griffith University, Gold Coast, Australia
| | - Peter J Yuide
- Department of Surgery, Logan Hospital, Meadowbrook, Australia.,School of Medicine, Griffith University, Gold Coast, Australia
| | - Sanjeev Naidu
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Australia
| | | | - Terence C Chua
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Australia.,School of Medicine, University of Queensland, Brisbane, Australia.,School of Medicine, Griffith University, Gold Coast, Australia
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12
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Margolin EJ, Wallace BK, Ha AS, Katz MJ, Mikkilineni N, Miles CH, Healy KA, Weiner DM, Shah O. Impact of an Acute Care Urology Service on Timelines and Quality of Care in the Management of Nephrolithiasis. J Endourol 2021; 36:351-359. [PMID: 34693737 DOI: 10.1089/end.2021.0506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The acute care surgery model has led to improved outcomes for emergent surgical conditions, but similar models of care have not been implemented in urology. Our department implemented an acute care urology (ACU) service in 2015, and the service evolved in 2018. We aimed to evaluate the impact of the ACU model on the management of nephrolithiasis. Materials and Methods: We conducted a retrospective review of all patients with urology consults in the emergency department for nephrolithiasis, who required surgical intervention from 2013 to 2019. Patients were divided into three cohorts based on date of consultation: Pre-ACU (2013-2014), Phase 1 (2015-2017), and Phase 2 (2018-2019). Results: We identified 733 patients with nephrolithiasis requiring intervention (162 pre-ACU, 334 Phase 1, and 237 Phase 2). Before ACU implementation, median time from consult to definitive intervention was 36 days. After ACU implementation, median time to intervention decreased to 22 days in Phase 1 (p < 0.001) and 15 days in Phase 2 (p < 0.001). On multivariable Cox regression, the hazard of definitive intervention improved in Phase 1 (hazard ratio [HR] 1.90, p < 0.001) and in Phase 2 (HR 1.80, p < 0.001). Rates of primary definitive intervention without initial decompression and loss to follow-up were also significantly improved, compared to the pre-ACU cohort. Conclusions: Implementation of a structured ACU service was associated with improved time to treatment for patients with acute nephrolithiasis, as well as increased primary definitive intervention and improved follow-up care. This model of care has potential to improve patient outcomes for nephrolithiasis and other acute urological conditions.
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Affiliation(s)
- Ezra J Margolin
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Brendan K Wallace
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Albert S Ha
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew J Katz
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Nina Mikkilineni
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Caleb H Miles
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Kelly A Healy
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - David M Weiner
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ojas Shah
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
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13
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Work Characteristics of Acute Care Surgeons at a Swiss Tertiary Care Hospital: A Prospective One-Month Snapshot Study. World J Surg 2021; 46:330-336. [PMID: 34677655 PMCID: PMC8532570 DOI: 10.1007/s00268-021-06350-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2021] [Indexed: 11/05/2022]
Abstract
Background Multiple acute care surgery (ACS) working models have been implemented. To optimize resources and on-call rosters, knowledge about work characteristics is required. Therefore, this study aimed to investigate the daily work characteristics of ACS surgeons at a Swiss tertiary care hospital. Methods Single-center prospective snapshot study. In February 2020, ACS fellows prospectively recorded their work characteristics, case volume and surgical case mix for 20 day shifts and 16 night shifts. Work characteristics were categorized in 11 different activities and documented in intervals of 30 min. Descriptive statistics were applied. Results A total of 432.5 working hours (h) were documented and characterized. The three main activities ‘surgery,’ ‘patient consultations’ and ‘administrative work’ ranged from 30.8 to 35.9% of the documented working time. A total of 46 surgical interventions were performed. In total, during day shifts, there were 16 elective and 15 emergency interventions, during night shifts 15 emergency interventions. For surgery, two peaks between 10:00 a.m.–02:00 p.m. and 08:00 p.m.–11:00 p.m. were observed. A total of 225 patient were consulted, with a first peak between 08:00 a.m. and 11:00 a.m. and a second, wider peak between 02:00 p.m. and 02:00 a.m. Conclusion The three main activities ‘surgery,’ ‘patient consultations’ and ‘administrative work’ were comparable with approximately one third of the working time each. There was a bimodal temporal distribution for both surgery and patient consultations. These results may help to improve hospital resources and on-call rosters of ACS services.
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14
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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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15
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Wong T, Zhang EJ, Elhajj AJ, Rizzo DM, Sexton KA, Pandit JJ, Tsai MH. The Power Law in Operating Room Management. J Med Syst 2021; 45:92. [PMID: 34494167 DOI: 10.1007/s10916-021-01764-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
The Acute Care Surgery model has been implemented by many hospitals in the United States. As complex adaptive systems, healthcare systems are composed of many interacting elements that respond to intrinsic and extrinsic inputs. Systems level analysis may reveal the underlying organizational structure of tactical block allocations like the Acute Care Surgery model. The purpose of this study is to demonstrate one method to identify a key characteristic of complex adaptive systems in the perioperative services. Start and end times for all surgeries performed at the University of Vermont Medical Center OR1 were extracted for two years prior to the transition to an Acute Care Surgery service and two years following the transition. Histograms were plotted for the inter-event times calculated from the difference between surgical cases. A power law distribution was fit to the post-transition histogram. The Kolmogorov-Smirnov test for goodness-of-fit at 95% level of significance shows the histogram plotted from post-transition inter-event times follows a power law distribution (K-S = 0.088, p = 0.068), indicating a Complex Adaptive System. Our analysis demonstrates that the strategic decision to create an Acute Care Surgery service has direct implications on tactical and operational processes in the perioperative services. Elements of complex adaptive systems can be represented by a power law distributions and similar methods may be applied to identify other processes that operate as complex adaptive systems in perioperative care. To make sustained improvements in the perioperative services, focus on manufacturing-based interventions such as Lean Six Sigma should instead be shifted towards the complex interventions that modify system-specific behaviors described by complex adaptive system principles when power law relationships are present.
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Affiliation(s)
- Timothy Wong
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, US
| | - Erik J Zhang
- University of Vermont Larner College of Medicine, Burlington, VT, US
| | - Andrea J Elhajj
- College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT, US
| | - Donna M Rizzo
- Department of Civil & Environmental Engineering, University of Vermont, Burlington, VT, US
| | - Kevin A Sexton
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, US
| | | | - Mitchell H Tsai
- Department of Anesthesiology, Department of Orthopaedics and Rehabilitation (By Courtesy), Department of Surgery (By Courtesy), University of Vermont Larner College of Medicine, Burlington, VT, US.
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16
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Hannan E, El-Masry S. The impact of the acute surgical assessment unit on the management of acute appendicitis: a single-centre review. Ir J Med Sci 2021; 191:1361-1367. [PMID: 34247309 PMCID: PMC9135865 DOI: 10.1007/s11845-021-02706-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/26/2021] [Indexed: 11/28/2022]
Abstract
Background Acute surgical assessment units (ASAUs) aim to optimise management of surgical patients compared to the traditional ‘on-call’ emergency department (ED) system. Acute appendicitis (AA) is the most common acute surgical condition requiring emergency surgery. Aim We set out to assess if the ASAU improved care provided to patients with AA compared to those managed through the ED. Methods Patients admitted via the ED with AA in the 6 months prior to opening the ASAU were compared to those admitted via the ASAU in the first six months following its implementation. Relevant data was collected on key performance indicators from their charts. Results In the ASAU cohort, the mean time to be seen was one hour less than the ED cohort (21 min vs 74 min). The mean time to surgery was also 8.8 h shorter. Most patients in the ASAU group (78.6%) underwent surgery during the day, compared to 40.3% of ED patients. The ASAU patients also had a lower postoperative complication rate (0.9% vs 3.9%), as well as a lower negative appendicectomy rate (14.2% vs 18.6%) and lower conversion-to-open surgery rate. Greater consultant supervision and presence was observed. Conclusions The ASAU has resulted in better outcomes for patients with AA than those admitted via ED. More operations were performed in safer daytime hours with greater consultant presence, allowing for improved senior support for trainee surgeons. Our study supports the role of the ASAU in improving the quality and efficiency of emergency general surgery.
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Affiliation(s)
- Enda Hannan
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, 109 Howth Road, Howth, Dublin 13, Ireland.
| | - Sherif El-Masry
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, 109 Howth Road, Howth, Dublin 13, Ireland
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17
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Sarmiento Altamirano D, Himmler A, Chango Sigüenza O, Pino Andrade R, Flores Lazo N, Reinoso Naranjo J, Sacoto Aguilar H, Fernández de Córdova L, Rodas E, Puyana JC, Salamea Molina JC. The Successful Implementation of a Trauma and Acute Care Surgery Model in Ecuador. World J Surg 2021; 44:1736-1744. [PMID: 32107595 DOI: 10.1007/s00268-020-05435-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND For years, surgical emergencies in Ecuador were managed on a case-by-case basis without significant standardization. To address these issues, the Regional Hospital Vicente Corral Moscoso adapted and implemented a model of "trauma and acute care surgery" (TACS) to the reality of Cuenca, Ecuador. METHODS A cohort study was carried out, comparing patients exposed to the traditional model and patients exposed to the TACS model. Variables assessed included number of surgical patients attended to in the emergency department, number of surgical interventions, number of surgeries performed per surgeon, surgical wait time, length of stay and in-hospital mortality. RESULTS The total number of surgical interventions increased (3919.6-5745.8, p ≤ 0.05); by extension, the total number of surgeries performed per surgeon also increased (5.37-223.68, p ≤ 0.05). We observed a statistically significant decrease in surgical wait time (10.6-3.2 h for emergency general surgery, 6.3-1.6 h for trauma, p ≤ 0.05). Length of stay decreased in trauma patients (9-6 days, p ≤ 0.05). Higher mortality was found in the traditional model (p ≤ 0.05) compared to the TACS model. CONCLUSIONS The implementation of TACS model in a resource-restrained hospital in Latin America had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients and length of stay in trauma patients. We also noted a statistically significant decrease in mortality. Savings to the overall system and patients can be inferred by decreased mortality, length of stay and surgical wait times. To our knowledge, this is the first implementation of a TACS model described in Latin America.
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Affiliation(s)
| | - Amber Himmler
- Division of Surgery, Medstar Georgetown University Hospital and Washington Hospital Center, Washington, DC, USA. .,University of Pittsburgh, Pittsburgh, PA, USA.
| | - Oscar Chango Sigüenza
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Raúl Pino Andrade
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad de Cuenca, Cuenca, Ecuador
| | - Nube Flores Lazo
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad de Cuenca, Cuenca, Ecuador
| | - Jeovanni Reinoso Naranjo
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad de Cuenca, Cuenca, Ecuador
| | - Hernán Sacoto Aguilar
- Facultad de Medicina, Universidad de Azuay, Cuenca, Ecuador.,Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Lenin Fernández de Córdova
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad Católica de Cuenca, Cuenca, Ecuador
| | - Edgar Rodas
- Division of Trauma and Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Juan Carlos Puyana
- Division of Trauma and Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Juan Carlos Salamea Molina
- Facultad de Medicina, Universidad de Azuay, Cuenca, Ecuador.,Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
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18
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Gounder J, Dissanayake B, Burstow MJ, Yuide PJ, Naidu S, Lancashire RP, Chua TC. Comparative analysis of emergency general surgery on-call structure and its impact on emergency appendicectomy outcomes. ANZ J Surg 2021; 91:616-621. [PMID: 33459510 DOI: 10.1111/ans.16558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/21/2020] [Accepted: 12/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND In Australia, there has been a shift from the traditional 'on-call' surgical model to the 'acute surgical unit' (ASU) model to improve outcomes in acute general surgery. Using emergency appendicectomy as a standardized procedure, we aimed to identify the different patterns of care between these on-call structures by comparing two metropolitan district hospitals; one that employs a traditional on-call model and the other, which employ the ASU model. METHODS Data on consecutive patients undergoing emergency appendectomies at the two hospitals (traditional and ASU model) between July 2018 and December 2018 were retrieved for retrospective review. Patient factors, preoperative factors, operative factors and post-operative outcomes were collected and tabulated for comparative analysis between the traditional versus ASU model of care. RESULTS Univariate analysis demonstrated that there were a greater proportion of consultant-led cases (P < 0.001), a shorter time to theatre (P = 0.047) and a greater number of out-of-hours operations (P < 0.001) in the ASU model compared to the traditional model. A larger proportion of patients from the traditional model underwent a computed tomography scan as part of their diagnostic workup compared to the ASU model (P < 0.001). There was no difference in negative appendicectomy rates, intraoperative conversion rates, post-operative complication rates or mean lengths of hospital stay between the two on-call models. CONCLUSION The ASU and traditional on-call model appears to achieve equivalent care outcomes for patients with acute appendicitis.
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Affiliation(s)
- Jaya Gounder
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Bhanuka Dissanayake
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Department of Surgery, Logan Hospital, Logan City, Queensland, Australia
| | - Matthew J Burstow
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Department of Surgery, Logan Hospital, Logan City, Queensland, Australia
| | - Peter J Yuide
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Department of Surgery, Logan Hospital, Logan City, Queensland, Australia
| | - Sanjeev Naidu
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Queensland, Australia
| | | | - Terence C Chua
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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19
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Complications of appendectomy and cholecystectomy in acute care surgery: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 89:576-584. [PMID: 32544106 DOI: 10.1097/ta.0000000000002825] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Acute care surgery (ACS) was initiated two decades ago to address timeliness and quality in emergency general surgery. We hypothesized that ACS has improved the management of acute appendicitis and biliary disease. METHODS A comprehensive systematic review and meta-analysis of outcome studies for emergent appendectomy and cholecystectomy from 1966 to 2017, comparing studies prior to and following ACS implementation, were performed. RESULTS Of 1,704 studies, 27 were selected for analysis (appendicitis, 16; biliary pathology, 7; both, 4). Following ACS introduction, the complication rate was significantly reduced in both appendectomy and cholecystectomy (risk ratios, 0.70; 95% confidence interval [CI], 0.57-0.85; I = 9.2% and relative risk, 0.62; 95% CI, 0.41-0.94; I = 63.5%) respectively. There was a significant reduction in the time from arrival in emergency until admission and from admission to operation (-1.37 hours: 95% CI, -1.93 to -0.80; -2.51 hours: 95% CI, -4.44 to -0.58) in the appendectomy cohort. Time to operation was shorter in the cholecystectomy group (-6.46 hours; 95% CI, -9.54 to -3.4). Length of hospital stay was reduced in both groups (appendectomy, -0.9 day; cholecystectomy, -1.09 day). There was a reduction in overall cost in cholecystectomy group (-US $854.37; 95% CI, -1,554.1 to -154.05). No statistical significance was detected for wound infection, abscess, conversion of laparoscopy to open technique, rate of negative appendectomy, after hours, readmission, and cost. CONCLUSION The implementation of ACS models in general surgery emergency care has significantly improved system and patient outcomes for appendicitis and biliary pathology. LEVEL OF EVIDENCE Systematic review and meta-analysis of a retrospective study, level III.
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20
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Yu X, Hu Y, Wang Z, He X, Xin S, Li G, Wu S, Zhang Q, Sun H, Lei G, Han W, Xue F, Wang L, Jiang J, Zhao Y. Developing a toolbox for identifying when to engage senior surgeons in emergency general surgery: A multicenter cohort study. Int J Surg 2020; 85:30-39. [PMID: 33278611 DOI: 10.1016/j.ijsu.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/24/2020] [Accepted: 11/03/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Having a senior surgeon present for high-risk patients is an important safety measure in emergency surgery, but 24-h consultant cover is not efficient. We aimed to develop a user-friendly toolbox (risk identification, outcome prediction and patient stratification) to support when to involve a senior surgeon. MATERIALS AND METHODS We included 11,901 general surgery patients (10.0% emergencies) in a multicenter prospective cohort in China (2015-2016). Patient information and surgeons' seniority were compared between emergency and elective surgery with the same procedure codes. Risk indicators common in these two surgical timings and specific to emergency surgery were identified, and their clinical importance was evaluated by a working group of 48 experienced surgeons. Predictive models for mortality and morbidity were built using logistic regression models. Stratification rules were created to balance patients' risk and surgeons' caseload with an Acute Call Team (ACT) model. RESULTS Emergency patients had significantly higher risks of mortality (3.6% vs 0.6%) and morbidity (7.8% vs 4.3%) than elective patients, but disproportionally fewer senior surgeons (59.9% vs 91.4%) were present. Using three risk indicators (American Society of Anesthesiologists score, age, blood urea nitrogen), C-statistic (95% CI) for prediction of emergency mortality was high [0.90 (0.84-0.96)]. It was less complex but equally accurate as two existing and validated models (0.86 [0.79-0.93] and 0.86 [0.77-0.95]). Using five indicators, C-statistic (95% CI) was moderate for prediction of overall morbidity [0.77 (0.72-0.83)], but high for severe morbidity [0.92 (0.88-0.97)]. Based on stratification rules of the ACT model, patient mortality and morbidity were 0.5% and 5.3% in the low-risk stratum (composing 64.6% of emergency caseload), and 15.9% and 29.0% in the very high-risk stratum (6.9% of caseload). CONCLUSION These findings show the practical feasibility of using a risk assessment tool to direct senior surgeons' involvement in emergency general surgery.
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Affiliation(s)
- Xiaochu Yu
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yaoda Hu
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences / School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Zixing Wang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences / School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xiaodong He
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shijie Xin
- The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Guichen Li
- The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Shizheng Wu
- Qinghai Provincial People's Hospital, Xining, Qinghai Province, China
| | - Qiang Zhang
- Qinghai Provincial People's Hospital, Xining, Qinghai Province, China
| | - Hong Sun
- Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Guanghua Lei
- Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Wei Han
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences / School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Fang Xue
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences / School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Lei Wang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences / School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jingmei Jiang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences / School of Basic Medicine, Peking Union Medical College, Beijing, China.
| | - Yupei Zhao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
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21
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Kinnear N, Han J, Tran M, Herath M, Jolly S, Hennessey D, Dobbins C, Sammour T, Moore J. Emergency general surgery models in Australia: a cross-sectional study. AUST HEALTH REV 2020; 44:952-957. [PMID: 33203508 DOI: 10.1071/ah19260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/28/2020] [Indexed: 11/23/2022]
Abstract
Objective Emergency general surgery (EGS) patients experience superior outcomes when cared for within an acute surgical unit (ASU) model. EGS structures in most Australian hospitals remain unknown. This study aimed to describe the national spectrum of EGS models. Methods A cross-sectional study was performed of all Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). The primary outcome was the incidence of each EGS model. Secondary outcomes were the relationship of the EGS model to objective hospital variables, and qualitative reasons for the choice of model. Results Of the 120 eligible hospitals, 119 (99%) participated. Sixty-four hospitals reported using an ASU (28%) or hybrid EGS model (26%), whereas the remaining 55 (46%) used a traditional model. ASU implementation was significantly more common among hospitals of greater peer group, bed number, surgeon pool and trauma service sophistication. Leading drivers for ASU commencement were aims to improve patient care and decrease after-hours operating, whereas common barriers against uptake were insufficient EGS patient load or surgeon on-call pool. Conclusions ASU or hybrid models of care may be more widespread than currently reported. The introduction of such structures is heavily dependent on hospital and staff size, trauma subspecialisation and EGS patient throughput. What is known about the topic? Traditionally, general surgical staff were rostered to elective operating and clinic duties, with emergency patients managed on an ad hoc basis. An ASU model, with a surgeon dedicated to EGS patients, has been associated with superior outcomes. However, the Australian uptake of this model is unknown. What does this paper add? This study enrolled 119 of 120 (99%) Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). Uptake of the ASU or hybrid model was more widespread than expected, existing in 64 of 119 (54%) centres. Factors for and against ASU implementation were also assessed. What are the implications for practitioners? Hospitals considering implementing an ASU or hybrid model will be reassured by the common reports of improved patient outcomes and decreased after-hours operating. However, potential hospitals must assess the suitability of the ASU model to their surgeon pool and EGS patient load.
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Affiliation(s)
- Ned Kinnear
- Department of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia. ; ; and Corresponding author.
| | - Jennie Han
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Minh Tran
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Matheesha Herath
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Samantha Jolly
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Derek Hennessey
- Department of Urology, Mercy University Hospital, Cork, Ireland.
| | - Christopher Dobbins
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Tarik Sammour
- Department of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia. ; ; and Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - James Moore
- Department of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia. ; ; and Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
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A systematic review of dedicated models of care for emergency urological patients. Asian J Urol 2020; 8:315-323. [PMID: 34401338 PMCID: PMC8356060 DOI: 10.1016/j.ajur.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 01/20/2020] [Accepted: 04/21/2020] [Indexed: 11/09/2022] Open
Abstract
Objective To systematically evaluate the spectrum of models providing dedicated resources for emergency urological patients (EUPs). Methods A search of Cochrane, Embase, Medline and grey literature from January 1, 2000 to March 26, 2019 was performed using methods pre-published on PROSPERO. Reporting followed Preferred Reporting Items for Systematic Review and meta-analysis guidelines. Eligible studies were articles or abstracts published in English describing dedicated models of care for EUPs, which reported at least one secondary outcome. Studies were excluded if they examined pathways dedicated only to single presentations, such as torsion, or outpatient solutions, such as rapid access clinics. The primary outcome was the spectrum of models. Secondary outcomes were time-to-theatre, length of stay, complications and cost. Results Seven studies were identified, totalling 487 patients. Six studies were conference abstracts, while one study was of full-text length but published in grey literature. Four distinct models were described. These included consultant urologists allocated solely to the care of EUPs (“Acute Urological Unit”) or dedicated registrars or operating theatres (“Hybrid structures”). In some services, EUPs bypassed emergency department assessment and were referred directly to urology (“Urological Assessment Unit”) or were managed by other dedicated means. Allocating services to EUPs was associated with reduced time-to-theatre, length of stay and hospital cost, and improved supervision of junior medical staff. Conclusion Multiple dedicated models of care exist for EUPs. Low-level evidence suggests these may improve outcomes for patients, staff and hospitals. Higher quality studies are required to explore patient outcomes and minimum requirements to establish these models.
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Gustafsson C, Dahlberg M, Sondén A, Järnbert-Pettersson H, Sandblom G. Is out-of-hours cholecystectomy for acute cholecystitis associated with complications? Br J Surg 2020; 107:1313-1323. [DOI: 10.1002/bjs.11633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/24/2020] [Accepted: 03/23/2020] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Existing data on the safety of out-of-hours cholecystectomy are conflicting. The aim of this study was to investigate whether out-of-hours cholecystectomy for acute cholecystitis is associated with a higher risk for complications compared with surgery during office hours.
Methods
This was a population-based cohort study. The Swedish Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography Register (GallRiks) was used to investigate the association between out-of-hours cholecystectomy for acute cholecystitis and complications developing within 30 days. Data from patients who underwent cholecystectomy between 2006 and 2017 were collected. Out-of-hours surgery was defined as surgery commencing between 19.00 and 07.00 hours on weekdays, or any time at weekends (Friday 19.00 hours to Monday 07.00 hours). Multivariable logistic regression analysis was used to assess the risk of complications, with time of procedure as independent variable. The proportion of open procedures and proportion of procedures exceeding 120 min were also analysed. Adjustments were made for sex, age, ASA grade, time between admission and surgery, and hospital-specific features.
Results
Of 11 153 procedures included, complications occurred within 30 days in 1573 patients (14·1 per cent). The adjusted odds ratio (OR) for complications for out-of-hours versus office-hours surgery was 1·12 (95 per cent c.i. 0·99 to 1·28). The adjusted OR for procedures completed as open surgery was 1·39 (1·25 to 1·54), and that for operating time exceeding 120 min was 0·63 (0·58 to 0·69).
Conclusion
Out-of-hours complications may relate to patient factors and the higher proportion of open procedures.
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Affiliation(s)
- C Gustafsson
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
| | - M Dahlberg
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
| | - A Sondén
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
| | - H Järnbert-Pettersson
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
| | - G Sandblom
- Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, Sjukhusbacken 10, S-118 83, Stockholm, Sweden
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24
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Wessels LE, Calvo RY, Sise MJ, Bowie JM, Butler WJ, Bansal V, Sise CB. Association of Operative Repair Type and Trauma Center Designation With Outcomes in Ruptured Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2020; 54:325-332. [PMID: 32079508 DOI: 10.1177/1538574420907193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Open repair of ruptured abdominal aortic aneurysm (rAAA) has shown improved outcomes at trauma centers. Whether the benefit of trauma center designation extends to endovascular repair of rAAA is unknown. METHODS Retrospective cohort study using the California Office of Statewide Health Planning and Development 2007 to 2014 discharge database to identify patients with rAAA. Data included demographic and admission factors, discharge disposition, International Classification of Diseases, Ninth Revision, Clinical Modification codes, and hospital characteristics. Hospitals were categorized by trauma center designation and teaching hospital status. The effect of repair type and trauma center designation (level I, level II, or other-other trauma centers and nondesignated hospitals) was evaluated to determine rates and risks of 9 postoperative complications, in-hospital mortality, and 30-day postdischarge mortality. RESULTS Of 1941 rAAA repair patients, 61.2% had open and 37.8% had endovascular; 1.0% had both. Endovascular repair increased over the study interval. Hospitals were 12.0% level I, 25.0% level II, and 63.0% other. A total of 48.7% of hospitals were teaching hospitals (level I, 100%; level II, 42.2%; and other, 41.8%). Endovascular repair was significantly more common at teaching hospitals (41.5% vs 34.3%, P < .001) and was the primary repair method at level I trauma centers (P < .001). Compared with open repair, endovascular repair was protective for most complications and in-hospital mortality. The risk for in-hospital mortality was highest among endovascular patients at level II trauma centers (hazard ratio 1.67, 95% confidence interval [CI]: 0.95-2.92) and other hospitals (hazard ratio 1.66, 95% CI: 1.01-2.72). CONCLUSIONS Endovascular repair overall was associated with a lower risk of adverse outcomes. Endovascular repair at level I trauma centers had a lower risk of in-hospital mortality which may be a result of their teaching hospital status, organizational structure, and other factors. The weight of the contributions of such factors warrants further study.
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Affiliation(s)
| | | | - Michael J Sise
- Trauma Service, Scripps Mercy Hospital, San Diego, CA, USA
| | - Jason M Bowie
- Trauma Service, Scripps Mercy Hospital, San Diego, CA, USA
| | | | - Vishal Bansal
- Trauma Service, Scripps Mercy Hospital, San Diego, CA, USA
| | - C Beth Sise
- Trauma Service, Scripps Mercy Hospital, San Diego, CA, USA
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25
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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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26
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Ang ZH, Wong S, Truskett P. General Surgeons Australia's 12-point plan for emergency general surgery. ANZ J Surg 2019; 89:809-814. [PMID: 31280492 DOI: 10.1111/ans.15327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/13/2022]
Abstract
In the last decade, emergency general surgery (EGS) in Australia and New Zealand has seen a transition from the traditional on-call system to the acute surgical unit (ASU) model. The importance and growing demand for EGS has resulted in the implementation of the General Surgeons Australia's 12-point plan for emergency surgery. Since its release, the 12-point plan has been used as a benchmark of a well-functioning ASU, both locally and abroad. This study aims to provide a descriptive review on the relevance of the 12-point plan to the ASU model and review the current evidence to support this framework. The review concludes that the establishment of the ASU model has met the aims set out by the Royal Australasian College of Surgeons for EGS. The 12-point plan is relevant and has good evidence to support its framework.
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Affiliation(s)
- Zhen Hao Ang
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shing Wong
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Philip Truskett
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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27
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Teo A, Wang C, Wilson RB. Time is of the essence: evaluation of emergency department triage and time performance in the preoperative management of acute abdomen. ANZ J Surg 2019; 89:1102-1107. [PMID: 31115159 DOI: 10.1111/ans.15255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 03/12/2019] [Accepted: 03/31/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute abdomen is a time-critical condition, which requires prompt diagnosis, initiation of first-line preoperative therapy and expedient surgical intervention. The earliest opportunity to intervene occurs at presentation to the emergency department triage. The aim of this audit was to evaluate the relationship between emergency triage and time performance measures in the preoperative management of abdominal emergencies. METHODS Retrospective audit of time performance measures of key clinical events from emergency triage. Patient characteristics, elapsed time from triage to commencement of fluid resuscitation, intravenous antibiotics and emergency surgery and post-operative outcomes were obtained from review of operative medical records data over a 1-year duration. RESULTS There was variability in triage allocation of patients with acute abdomen requiring urgent surgery. Category 3 was the most commonly assigned triage category (65.6%). The majority of patients (94.8%) had initial clinical assessment within the National Emergency Access Target '4-hour' rule, and 41.7% seen within 1-h from triage. Despite this, in cases of intra-abdominal sepsis, there was nearly a fourfold elapsed time for first dose intravenous antibiotics, beyond the 1-h recommendation in the Sepsis Kills pathway. There was non-significant trend in faster overall time performances with successive higher triage category allocation. CONCLUSION This study highlights an opportunity to consider alternative triage methods or fast-track of patients with acute abdomen to promote early surgical assessment, resuscitation, antibiotic therapy and definitive intervention.
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Affiliation(s)
- Adrian Teo
- Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,The University of New South Wales, Sydney, New South Wales, Australia
| | - Cindy Wang
- Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Robert B Wilson
- Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,The University of New South Wales, Sydney, New South Wales, Australia
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28
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Has Symptom-Based Admission Replaced Diagnosis in the Emergency Department? An 18-Year Review of Emergency General Surgical Admissions at Royal Perth Hospital. World J Surg 2019; 43:2186-2193. [PMID: 31089767 DOI: 10.1007/s00268-019-05026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Classical medical teaching has made a clear distinction between signs and symptoms, and diagnosis. However, at the time of ward admission, a diagnosis may remain unclear. We propose administrative pressures during the admission process may have reduced the ability for pathological diagnosis. This may result in increased hospitalisation for investigation of signs and symptoms, rather than for treatment of clear diagnoses. We sought to further clarify this hypothesis and investigate changes in the nature of admissions during the last two decades in an adult emergency general surgery service. METHODS A retrospective analysis of emergency general surgical admissions during four six-month time periods, between 2000 and 2018, was conducted. The six-month periods were spaced evenly during the 18-year study. Demographic information, emergency department length of stay, incidence of a pathological diagnosis on ward admission and accuracy of admission diagnosis were analysed. RESULTS 2763 patients were admitted in the four six-month time periods. A significant reduction in number of patients admitted with a pathological diagnosis was noted between the 2012 and 2018 study periods (p < 0.05), with 21.2% of patients admitted in 2018 for investigation of signs and symptoms. The incidence of an accurate admission diagnosis (as assessed by the discharge diagnosis) ranged from 62.3 to 63.6% and did not differ significantly by year. CONCLUSION Between 2012 and 2018, there was a significant increase in the number of emergency general surgical patients admitted for investigation of signs and symptoms. However, accuracy of admission diagnosis was unchanged during the study period.
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29
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Kinnear N, Bramwell E, Frazzetto A, Noll A, Patel P, Hennessey D, Otto G, Dobbins C, Sammour T, Moore J. Acute surgical unit improves outcomes in appendicectomy. ANZ J Surg 2019; 89:1108-1113. [PMID: 30989789 DOI: 10.1111/ans.15141] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/28/2019] [Accepted: 02/11/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Ned Kinnear
- Department of SurgeryLyell McEwin Hospital Adelaide South Australia Australia
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
| | - Eliza Bramwell
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
| | - Alannah Frazzetto
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
| | - Amy Noll
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
| | - Prajay Patel
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
| | | | - Greg Otto
- Department of SurgeryLyell McEwin Hospital Adelaide South Australia Australia
| | - Christopher Dobbins
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Tarik Sammour
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - James Moore
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
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30
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Nel D, Kloppers C, Rayamajhi S, Klopper JH. Logistical factors associated with adverse outcomes following emergency surgery in an acute care surgical unit. Eur J Trauma Emerg Surg 2019; 46:377-382. [PMID: 30617401 DOI: 10.1007/s00068-018-01064-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 12/26/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE The Acute Care Surgical Unit at Groote Schuur Hospital was established in 2010 and is the first of its kind in Africa. The aim of this study was to describe the outcomes of emergency surgical cases, as well as determine the logistical factors associated with adverse outcomes following surgery within the unit. METHODS This study was a retrospective audit which reviewed the folders of adult patients who underwent an emergency surgical procedure from July 2016 to July 2017. The primary outcome was a major adverse event (AE) which was defined by a Clavien-Dindo score of 3-5. A number of logistical factors related to patient admission and operation were evaluated for association with outcomes. RESULTS A total of 271 patients were included with a mean age of 47 years, with 48% females and 52% males. A major AE was recorded for 13% of patients. The following factors were found to be predictive of a major AE: referral from outside the hospital, urgent booking colour code, reoperation, and consultant most senior surgeon present during procedure. Patient admission/surgery performed outside of normal working hours, being booked for surgery on admission, as well as delay to surgery beyond colour code were not associated with a major AE. CONCLUSION Apart from the traditional clinical parameters, factors related to perioperative logistics may contribute to the risk of a major AE after emergency surgery and should be considered for inclusion in more comprehensive predictive models for adverse outcomes within an acute care surgery unit.
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Affiliation(s)
- Daniel Nel
- Division of General Surgery, Groote Schuur Hospital, Cape Town, South Africa.
| | - Christo Kloppers
- Head of Acute Care Surgery Unit, Division of General Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Shreya Rayamajhi
- Division of General Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Juan H Klopper
- Division of General Surgery, Groote Schuur Hospital, Cape Town, South Africa
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31
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Acute Care Surgery Model and Outcomes in Emergency General Surgery. J Am Coll Surg 2019; 228:21-28.e7. [DOI: 10.1016/j.jamcollsurg.2018.07.664] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/17/2018] [Indexed: 11/19/2022]
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32
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Effect of Delay to Operation on Outcomes in Patients with Acute Appendicitis: a Systematic Review and Meta-analysis. J Gastrointest Surg 2019; 23:210-223. [PMID: 29980978 DOI: 10.1007/s11605-018-3866-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/25/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many studies have investigated the association between time interval and incidence of complicated appendicitis and post-operative surgical site infection (SSI), but the results are controversial. METHODS A systematic search of the electronic databases identified studies that investigated the association of appendectomy delay with complicated appendicitis and SSI among patients with acute appendicitis. Qualitative and quantitative meta-analysis of the results was conducted. RESULTS Twenty-one studies were included in the final analysis. Meta-analysis showed no significant difference in complicated appendicitis incidence between patients in the 6-12 h, > 12 and < 6 h groups (OR 1.07, 95% CI 0.89-1.30, p = 0.47; OR 1.04, 95% CI 0.88-1.22, p = 0.64). Comparison of the 6-12 h category with the < 6 h category of in-hospital delay revealed significant associations between longer in-hospital delay and increased risk of post-operative SSI (OR 1.40, 95% CI 1.11-1.77, p = 0.004). Patients in the 24-48 h category had 1.99- and 1.84-fold (p < 0.05) higher odds of developing complicated appendicitis compared to patients in the < 24 h category for pre-hospital delay and total delay, respectively (OR 1.99, 95% CI 1.35-2.94, p = 0.0006; OR 1.84, 95% CI 1.05-3.21, p = 0.03). When pre-hospital and total delay time extended to more than 48 h, the odds of risk increased 4.62- and 7.57-fold, respectively (OR 4.62, 95% CI 2.99-7.13, p < 0.00001; OR 7.57, 95% CI 6.14-9.35, p = < 0.00001). CONCLUSION Complicated appendicitis incidence was associated with overall elapsed time from symptom onset to admission or operation; short appendectomy in-hospital delay did not increase the risk of complicated appendicitis but was associated with a slightly increased risk of SSI. Prompt surgical intervention is warranted to avoid additional morbidity, enabling quicker recovery in this population.
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33
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Aranda-Narváez JM, Tallón-Aguilar L, López-Ruiz JA, Pareja-Ciuró F, Jover-Navalón JM, Turégano-Fuentes F, Navarro-Soto S, Ceballos-Esparragón J, Pérez-Díaz L. The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain. Cir Esp 2018; 97:3-10. [PMID: 30415793 DOI: 10.1016/j.ciresp.2018.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023]
Abstract
The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lola Pérez-Díaz
- Hospital General Universitario Gregorio Marañón, Madrid, España
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34
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Paine AN, Krompf BL, Borrazzo EC, Ahern TP, Malhotra AK, Norotsky MC, Tsai MH. The Impact of an Acute Care Surgery Model on General Surgery Service Productivity. ACTA ACUST UNITED AC 2018; 12:26-30. [PMID: 31131335 DOI: 10.1016/j.pcorm.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Acute Care Surgery (ACS) model has been widely adopted by hospitals across the United States, with ACS services managing emergency general surgery (EGS) patients previously treated by general surgery (GS) services. We evaluated the operational and financial impact of an ACS service model on general surgeons at an academic medical center. METHODS Using WiseOR® (Palo Alto, CA), we compared surgical case volumes for the GS service two years before (October, 2013 - September, 2015) and two years after (October, 2015 - September, 2017) implementation of an ACS service at the University of Vermont Medical Center. From financial reports, we obtained monthly wRVUs, clinical FTEs, net patient revenue, and payer mix for the GS service and compared the two years before and after ACS model implementation. RESULTS There was a significant reduction in the average number of cases performed by the GS service following ACS service implementation (monthly mean ± SD, 139.1 ± 16.0 vs. 116.7 ± 14.0, p < 0.001). The normal-hours caseload remained stable, while a significant decrease in after-hours cases accounted for the reduction in overall volume. Despite the reduction in operative volume, the decrease in mean monthly wRVU/FTE for the GS service when comparing the pre- and post- ACS periods did not reach statistical significance (614.9 ± 82.9 vs. 576.3 ± 62.1, p = 0.08).There was a significant increase in average monthly clinic-derived wRVU/FTE for the GS service (106.3 ± 13.5 vs. 120.5 ± 16.4, p = 0.007). CONCLUSIONS Shifting EGS patient management from the GS to ACS service did not negatively impact the productivity of the GS service. Background
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Affiliation(s)
- Adam N Paine
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT.,Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Bradley L Krompf
- Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Edward C Borrazzo
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT.,Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Thomas P Ahern
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT
| | - Ajai K Malhotra
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT.,Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Mitchell C Norotsky
- Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, VT.,Department of Surgery, The University of Vermont Medical Center, Burlington, VT
| | - Mitchell H Tsai
- Department of Anesthesiology and Department of Orthopaedics and Rehabilitation (by courtesy), The University of Vermont Larner College of Medicine, Burlington, VT
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Efficiency of care and cost for common emergency general surgery conditions: Comparison by surgeon training and practice. Surgery 2018; 164:651-656. [PMID: 30098814 DOI: 10.1016/j.surg.2018.05.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/16/2018] [Accepted: 05/31/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Our institutional emergency general surgery service is staffed by both trauma and critical care-trained surgeons and other boarded general surgeons and subspecialists. We compared efficiency of care for common emergency general surgery conditions between trauma and critical care-trained surgeons and boarded general surgeons and subspecialists. METHODS Adults admitted between February 2014 and May 2017 with acute appendicitis, acute cholecystitis, intestinal obstruction, incarcerated hernia, or other acute abdominal diagnoses seen by emergency general surgery service were included. Demographic characteristics, consulting surgeon, operations, outcomes, and cost data were obtained. RESULTS A total of 1,363 patients were included: 384 (28.2%) with acute appendicitis, 477 (35.0%) with acute cholecystitis, 406 (29.8%) with intestinal obstruction, 22 (1.6%) with incarcerated hernia, and 74 (5.4%) with other acute abdominal diagnoses. Trauma and critical care-trained surgeons saw 836 (61.3%) patients. There was no difference in operative management between the two groups, however, trauma and critical care-trained surgeons had significantly less time to the operative room (7.0 vs 12.9 hours; P < .001), without a difference in duration of stay or costs. The subgroups of acute appendicitis and acute cholecystitis when treated by trauma and critical care-trained surgeons had less time to the operative room (8.4 vs 17.4 hours; P < .001), shorter hospital stay (2.5 vs 2.8 days; P = .021), and less emergency department cost ($822 vs $876; P = .012). CONCLUSION Compared with boarded general surgeons and subspecialists, trauma and critical care-trained surgeons provide more efficient care for common emergency general surgery conditions, with less time from consultation to the operative room.
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Wang E, Jootun R, Foster A. Management of acute appendicitis in an acute surgical unit: a cost analysis. ANZ J Surg 2018; 88:1284-1288. [PMID: 29998614 DOI: 10.1111/ans.14727] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/15/2018] [Accepted: 05/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The acute surgical unit (ASU) model of acute general surgery care offers efficient patient assessment, improved clinical outcomes and has been demonstrated to be cost-efficient. Despite this, the management of acute appendicitis in our ASU was found to be highly cost-negative. This study sought to identify the drivers of increased cost. METHODS A retrospective cost analysis of all patients with uncomplicated acute appendicitis in 2016 was undertaken to investigate the drivers of increased cost. The patient-level costing approach was used to assign cost to patients. RESULTS The ASU management of uncomplicated appendicitis was found to have made a net loss of $625 000 in 2016. This study identified that the three largest cost drivers in appendicitis care were hospital overheads, bed day length of admission cost and operating theatre costs. Radiology, pathology and pharmacy costs did not affect total cost significantly. CONCLUSION Two key targets for improvement were identified. First, reduced theatre turnaround times will allow more efficient theatre utilization. Second, improved after-hours and weekend theatre availability will reduce preoperative waiting time-related cost.
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Affiliation(s)
- Edward Wang
- Acute Surgical Unit, Department of General Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Ravish Jootun
- Acute Surgical Unit, Department of General Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Amanda Foster
- Acute Surgical Unit, Department of General Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
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DeGirolamo K, D'Souza K, Apte S, Ball CG, Armstrong C, Reso A, Widder S, Mueller S, Gillman LM, Singh R, Nenshi R, Khwaja K, Minor S, de Gara C, Hameed SM. A day in the life of emergency general surgery in Canada: a multicentre observational study. Can J Surg 2018; 61:13517. [PMID: 29806805 DOI: 10.1503/cjs.013517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Emergency general surgery (EGS) services are gaining popularity in Canada as systems-based approaches to surgical emergencies. Despite the high volume, acuity and complexity of the patient populations served by EGS services, little has been reported about the services' structure, processes, case-mix or outcomes. This study begins a national surveillance effort to define and advance surgical quality in an important and diverse surgical population. METHODS A national cross-sectional study of EGS services was conducted during a 24-hour period in January 2017 at 14 hospitals across 7 Canadian provinces recruited through the Canadian Association of General Surgeons Acute Care Committee. Patients admitted to the EGS service, new consultations and off-service patients being followed by the EGS service during the study period were included. Patient demographic information and data on operations, procedures and complications were collected. RESULTS Twelve sites reported resident coverage. Most services did not include trauma. Ten sites had protected operating room time. Overall, 393 patient encounters occurred during the study period (195/386 [50.5%] operative and 191/386 [49.5%] nonoperative), with a mean of 3.8 operations per service. The patient population was complex, with 136 patients (34.6%) having more than 3 comorbidities. There was a wide case-mix, including gallbladder disease (69 cases [17.8%]) and appendiceal disease (31 [8.0%]) as well as complex emergencies, such as obstruction (56 [14.5%]) and perforation (23 [5.9%]). CONCLUSION The characteristics and case-mix of these Canadian EGS services are heterogeneous, but all services are busy and provide comprehensive operative and nonoperative care to acutely ill patients with high levels of comorbidity.
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Affiliation(s)
- Kristin DeGirolamo
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Karan D'Souza
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Sameer Apte
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Chad G Ball
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Christopher Armstrong
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Artan Reso
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Sandy Widder
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Sarah Mueller
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Lawrence M Gillman
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Ravinder Singh
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Rahima Nenshi
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Kosar Khwaja
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Samuel Minor
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - Chris de Gara
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
| | - S Morad Hameed
- From the Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC (DeGirolamo, Hameed); the Faculty of Medicine, University of British Columbia, Vancouver, BC (D'Souza); the Department of Surgery, University of Alberta, Edmonton, Alta. (Apte, Widder, de Gara); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Armstrong, Reso); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Mueller); the Department of Surgery, University of Manitoba, Winnipeg, Man. (Gillman); the Department of Surgery, Northern Ontario School of Medicine, North Bay, Ont. (Singh); the Department of Surgery, McMaster University, Hamilton, Ont. (Nenshi); the Department of Surgery, McGill University, Montréal, Que. (Khwaja); the Department of Surgery, Dalhousie University, Halifax, NS (Minor); and the Department of Trauma Services, Vancouver General Hospital, Vancouver, BC (Hameed)
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Morgan DJ, Ho KM, Kolybaba ML, Ong YJ. Adverse outcomes after planned surgery with anticipated intensive care admission in out-of-office-hours time periods: a multicentre cohort study. Br J Anaesth 2018; 120:1420-1428. [PMID: 29793607 DOI: 10.1016/j.bja.2018.02.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/08/2017] [Accepted: 03/06/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Increasing mortality for patients admitted to hospitals during the weekend is a contentious but well described phenomenon. However, it remains uncertain whether adverse outcomes, including prolonged hospital length-of-stay (LOS), may also occur after patients undergoing major planned surgery are admitted to an intensive care unit (ICU) out-of-office-hours, either during weeknights (after 18:00) or on weekends. METHODS All planned surgical admissions requiring admission to one of 183 ICUs across Australia and New Zealand between 2006 and 2016 were included in this retrospective population-based cohort study. Primary outcomes were hospital LOS and hospital mortality. RESULTS Of the total 504 713 planned postoperative ICU admissions, 33.6% occurred during out-of-office-hours. After adjusting for available risk factors, out-of-office-hours ICU admissions were associated with a significant increase in hospital LOS [+2.6 days, 95% confidence interval (CI) 2.5-2.6], mortality [odd ratio (OR) 1.5, 95%CI 1.4-1.6], and a reduced chance of being directly discharged home (OR 0.8, 95%CI 0.8-0.8). The strongest association for adverse outcomes occurred with weekend ICU admissions (hospital LOS: +3.0 days, 95%CI 3.2-3.6; hospital mortality: OR 1.7, 95%CI 1.6-1.8). Clustering of adverse outcomes by hospitals was not observed in the generalised estimating equation analyses. CONCLUSIONS Despite a greater clinical staff availability and higher monitoring levels, planned surgery requiring anticipated out-of-office-hours ICU admission was associated with a prolonged hospital LOS, reduced discharge directly home, and increased mortality compared with in-office-hours admissions. Our findings have potential clinical, economic and health policy implications on how complex planned surgery should be planned and managed.
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Affiliation(s)
- D J Morgan
- Department of Intensive Care Medicine, St John of God Subiaco Hospital, Perth, Western Australia, Australia.
| | - K M Ho
- Department of Intensive Care Medicine, St John of God Subiaco Hospital, Perth, Western Australia, Australia; School of Population Health, The University of Western Australia, Perth, Western Australia, Australia; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia
| | - M L Kolybaba
- Department of Intensive Care Medicine, St John of God Subiaco Hospital, Perth, Western Australia, Australia
| | - Y J Ong
- Department of Intensive Care Medicine, St John of God Subiaco Hospital, Perth, Western Australia, Australia
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Impact of an acute surgical unit in appendicectomy outcomes: A systematic review and meta-analysis. Int J Surg 2018; 50:114-120. [PMID: 29337180 DOI: 10.1016/j.ijsu.2017.12.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/20/2017] [Accepted: 12/28/2017] [Indexed: 01/06/2023]
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Emergency laparotomy outcomes before and after the introduction of an acute surgical unit. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2017.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Mathur S, Lim WW, Goo TT. Emergency general surgery and trauma: Outcomes from the first consultant-led service in Singapore. Injury 2018; 49:130-134. [PMID: 28899559 DOI: 10.1016/j.injury.2017.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/29/2017] [Accepted: 09/01/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is a significant burden on public health systems from emergency surgical and trauma (ESAT) patients. In Western countries, the response has been to separate acute and elective surgery with the creation of a new sub-specialty: acute care surgery. Dedicated acute units have shown improvements in efficiency and clinical outcomes for patients. The aim of this study was to assess the results of the first such unit in Singapore. MATERIALS AND METHODS A retrospective analysis was performed of a 12-month period of acute admissions between May 2014 and April 2015, with comparison of 6-months before and after the creation of the ESAT service. The ESAT service was a consultant led dedicated team managing all daily acute and trauma patients. Demographic, efficiency and clinical outcome key performance indicators were compared. RESULTS There were 2527 acute admissions split between the two time periods. The ESAT service (N=1279) managed soft tissue infections (257, 20%), appendicitis (199, 16%) and biliary disease (175, 14%) most commonly. The most common of the 573 procedures performed were incision and drainage (242, 42%), appendicectomy (188, 33%) and laparotomy (84, 16%). Clinical outcome during the ESAT service included reduction in overall mean length of stay (4.5d to 3.5d, P<0.01) and mortality (24/1248 (1.9%) to 11/1279 (0.9%), P=0.03). Efficiency gains in theatre booking time, ED surgical review and overall costs were also noted. CONCLUSION The creation of an ESAT service has led to improved efficiency of care with no worsening of clinical outcomes for acute general surgical and trauma patients.
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Affiliation(s)
- Sachin Mathur
- Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
| | - Woan Wui Lim
- Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
| | - Tiong Thye Goo
- Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
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Stevens CL, Brown C, Watters DAK. Measuring Outcomes of Clinical Care: Victorian Emergency Laparotomy Audit Using Quality Investigator. World J Surg 2017; 42:1981-1987. [DOI: 10.1007/s00268-017-4418-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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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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Murphy PB, DeGirolamo K, Van Zyl TJ, Allen L, Haut E, Leeper WR, Leslie K, Parry N, Hameed M, Vogt KN. Impact of the Acute Care Surgery Model on Disease- and Patient-Specific Outcomes in Appendicitis and Biliary Disease: A Meta-Analysis. J Am Coll Surg 2017; 225:763-777.e13. [PMID: 28918345 DOI: 10.1016/j.jamcollsurg.2017.08.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/13/2017] [Accepted: 08/14/2017] [Indexed: 12/29/2022]
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Navarro AP, Hardy E, Oakley B, Mohamed E, Welch NT, Parsons SL. The front-line general surgery consultant as a new model of emergency care. Ann R Coll Surg Engl 2017; 99:550-554. [PMID: 28682130 DOI: 10.1308/rcsann.2017.0081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Emergency general surgery services in England are undergoing rapid structural change with the aim of improving care. In our centre, the key issues identified were high numbers of admissions, inappropriate referrals, prolonged waiting times, delayed senior input and poor patient satisfaction. A new model was launched in January 2015 to address these issues: the surgical triage unit (STU). This study assesses the success of the new service. Methods All emergency general surgical admissions during a five-month period before introduction of the STU were compared with those of a comparable five-month period after its introduction. Process, clinical and patient experience outcomes were assessed to identify improvement. Results Attendance fell from 3,304 patients in the 2014 cohort to 2,830 in the 2015 cohort. During the 2015 study period, 279 more patients were discharged on the same day. Resource requirement fell by 2,635 bed days (23%). The number of true surgical emergencies remained consistent. Rates for reattendance (7.8% for 2014 vs 8.1% for 2015) and readmission (5.7% for 2014 vs 5.7% for 2015) showed no significant difference. Patient experience data demonstrated a significant improvement in both net promoter score (64.1 vs 82.2) and number of complaints (34 vs 5). Clinical outcomes for low risk procedures remained similar. Emergency laparotomy in-hospital mortality fell (11.4% vs 10.3%) despite preoperative risk stratification suggesting a risk burden that was significantly higher than the national average. Conclusions This novel model of emergency general surgery provision has improved clinical efficiency, patient satisfaction and outcomes. We encourage other units to consider similar programmes of service improvement.
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Affiliation(s)
- A P Navarro
- Nottingham University Hospitals NHS Trust , UK
| | - Ejo Hardy
- Nottingham University Hospitals NHS Trust , UK
| | - B Oakley
- Nottingham University Hospitals NHS Trust , UK
| | - E Mohamed
- Nottingham University Hospitals NHS Trust , UK
| | - N T Welch
- Nottingham University Hospitals NHS Trust , UK
| | - S L Parsons
- Nottingham University Hospitals NHS Trust , UK
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Kinnear N, Britten-Jones P, Hennessey D, Lin D, Lituri D, Prasannan S, Otto G. Impact of an acute surgical unit on patient outcomes in South Australia. ANZ J Surg 2017; 87:825-829. [PMID: 28681948 DOI: 10.1111/ans.14100] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/06/2017] [Accepted: 05/09/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Compared with traditional (Trad) systems of managing emergency surgical presentations, the acute surgical unit (ASU) model provides an on-site registrar, on-call surgeon and dedicated emergency theatre, 24 h/day. To date, there have been no Australasian ASU studies of >3000 patients, nor from South Australia. METHODS A retrospective historical control study compared the outcomes of adults admitted to the Lyell McEwin Hospital in the Trad (1 February 2010 to 31 July 2012) and ASU periods (1 August 2012 to 31 January 2015), who underwent an emergency general surgical procedure. RESULTS A total of 4074 patients met inclusion criteria; 1688 and 2386 patients during the Trad and ASU periods, respectively. The cohorts were not significantly different in median age, gender or American Society of Anesthesiologists scores. Compared with the Trad period, improved median time from emergency department referral to theatre start (19.4 h versus 17.9 h, P < 0.0001) and median length of stay (2.32 days versus 2.06 days, P < 0.0001) were observed during the ASU period. The proportion of procedures performed in-hours was similar (77.9% versus 79.6%, P = 0.18). Secondary outcomes of rates of intensive care unit admission, emergency department representation within 30 days, in-hospital mortality and 1-year all-cause mortality were unchanged. CONCLUSION Institution of an ASU was associated with decreased time from referral to theatre and reduced length of stay. The proportion of cases performed in-hours did not change. This may be related to the high Trad period rate and increased workload. These findings represent the largest Australasian study of an ASU and support the current model of care.
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Affiliation(s)
- Ned Kinnear
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia.,Department of Urology, Austin Health, Melbourne, Victoria, Australia
| | - Philip Britten-Jones
- Department of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Derek Hennessey
- Department of Urology, Austin Health, Melbourne, Victoria, Australia
| | - Diwei Lin
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Darren Lituri
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Subhita Prasannan
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Greg Otto
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
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Farrell M, Murphy E, Caplan R, Bradley K, Rubino M, Cipolle M. Management of Appendicitis with the Implementation of an Acute Care Surgery Service in a Community Teaching Hospital. Am Surg 2017. [DOI: 10.1177/000313481708300717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Allaway MGR, Eslick GD, Kwok GTY, Cox MR. The Established Acute Surgical Unit: A reduction in nighttime appendicectomy without increased morbidity. Int J Surg 2017; 43:81-85. [PMID: 28552813 DOI: 10.1016/j.ijsu.2017.05.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/19/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Nighttime surgery for non-life threatening disease has been associated with poorer outcomes, but delaying surgery for acute appendicitis may also be detrimental. The aim was to assess the effect of the Acute Surgical Unit [ASU] model on nighttime surgery rates and outcomes for patients undergoing appendicectomy. METHOD A retrospective review of medical records of patients having an appendicectomy. Primary outcomes were nighttime surgery rate, time from presentation to surgery, perforation rate, complication rate and length of stay. RESULTS There was a large increase in workload: Pre ASU 278, Early ASU 553 and Est. ASU 923. There was a significant decrease in nighttime surgery rates: Pre ASU 46.9%, Early ASU 30.2% and Established ASU 28.3% (Pre vs. Early p < 0.001; Pre vs. Est. p < 0.001; Early vs. Est p = 0.004). When comparing the Pre ASU and Established ASU groups there was an increase in mean time from presentation to surgery (Pre 14.43 Hrs, Est. 18.65 Hrs; p = 0.001), an increase in perforation rate that was not significant (Pre 9.8%, Est. 14.2%; p = 0.05) and similar complication rates (Pre 8.66%, Est. 7.04%; p = 0.37). There was a significant decrease in length of stay between the Early and Established ASU groups (Pre 3.1 D, Est. 2.8D, p = 0.01). At our institution there was no statistically significant increase in complications for patients undergoing nighttime appendicectomy (Night 10.0%, Day 8.2%; p = 0.16). CONCLUSION There was a significant decrease in nighttime surgery, without any difference in morbidity or length of stay for patients treated within the Established ASU (compared to Pre ASU group). LEVEL OF EVIDENCE IIb.
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Affiliation(s)
| | - Guy D Eslick
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; The Whiteley-Martin Research Centre, The University of Sydney, Nepean Hospital, Penrith, NSW, Australia
| | - Grace T Y Kwok
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Michael R Cox
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; The Whiteley-Martin Research Centre, The University of Sydney, Nepean Hospital, Penrith, NSW, Australia.
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Tran S, Choi V, Hepburn K, Hewitt N, Zhou J, Chan DL, Talbot ML. Subspecialty approach for the management of acute cholecystitis: an alternative to acute surgical unit model of care. ANZ J Surg 2017; 87:560-564. [PMID: 28512772 DOI: 10.1111/ans.13986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/01/2017] [Accepted: 03/02/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute cholecystitis is a common condition. Recent studies have shown an association between creation of an acute surgical unit (ASU) and improved outcomes. This study aimed to evaluate the outcomes of a subspecialty based approach to the management of acute cholecystitis as an alternative to the traditional 'generalist' general surgery approach or the ASU model. METHOD A 6-year retrospective analysis of outcomes in patients admitted under a dedicated upper gastrointestinal service for acute cholecystitis undergoing emergency laparoscopic cholecystectomy. RESULTS Seven hundred emergency laparoscopic cholecystectomies were performed over this time. A total of 486 patients were available for analysis. The median time to operation was 2 days and median length of operation was 80 min. A total of 86.9% were performed during daylight hours. Eight cases were converted to open surgery (1.6%). Intra-operative cholangiography was performed in 408 patients. The major complication rate was 8.2%, including retained common bile duct stones (2.3%), sepsis (0.2%), post-operative bleeding (0.4%), readmission (0.6%), bile leak (2.1%), AMI (0.4%), unscheduled return to theatre (0.6%) and pneumonia (0.8%). There were no mortalities and no common bile duct injuries. CONCLUSION Over a time period that encompasses the current publications on the ASU model, a subspecialty model of care has shown consistent results that exceed established benchmarks. Subspecialty management of complex elective pathologies has become the norm in general surgery and this study generates the hypothesis that subspecialty management of patients with complex emergency pathologies should be considered a valid alternative to ASU. Access block to emergency theatres delays treatment and prolongs hospital stay.
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Affiliation(s)
- Sonia Tran
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Vincent Choi
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Kirsten Hepburn
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Nathan Hewitt
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Joel Zhou
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia.,UNSW Department of Surgery, St George Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Daniel L Chan
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia.,UNSW Department of Surgery, St George Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Michael L Talbot
- Upper Gastrointestinal Surgery Unit, St George Hospital, Sydney, New South Wales, Australia.,UNSW Department of Surgery, St George Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
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