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Yoon KW, Yoo K, Choi K, Gil E, Park CM, Lee D. The implementation of the acute care surgery model in the management of patients with acute appendicitis - A 5-year single-center, retrospective experience: An observational study. Medicine (Baltimore) 2024; 103:e38927. [PMID: 39029014 DOI: 10.1097/md.0000000000038927] [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] [Indexed: 07/21/2024] Open
Abstract
We conducted this study to assess the effects of the acute care surgery (ACS) model in the management of patients with acute appendicitis (AA) based on our 5-year single-center, retrospective experience. The current single-center, retrospective, observational study was conducted in a consecutive series of the patients with AA who had been surgically treated at a tertiary referral hospital in Seoul, Korea, between January 2016 and December 2020. At our institution, the ACS model was first introduced in March 2018. Therefore, our clinical series of the patients were divided into 2 groups: the pre-ACS group (March 2014 to February 2018) and the post-ACS group (March 2018 to December 2022). Key time intervals include emergency department registration to request for surgical consultation, request for surgical consultation to decision on surgery, decision-to-operating room, time to decision on surgery and length of emergency department stay. Moreover, outcomes include rates of perforation and complications and discharge within 24 or 48 hours. We compared key time intervals, outcomes, and length of hospital stay between the 2 groups. A total of 900 patients with AA were finally included in the current study, 447 and 453 of whom were divided into the pre-ACS group (n = 447) and the post-ACS group (n = 453), respectively. There were significant differences in key time intervals, outcomes, and length of hospital stay between the 2 groups (P < .05). In conclusion, our results showed that the implementation of the ACS model was effective in improving key time intervals, rates of perforation, and discharge within 24 or 48 hours in the patients with AA.
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Affiliation(s)
- Kyoung Won Yoon
- Division of Critical Care, Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Keesang Yoo
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoungjin Choi
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eunmi Gil
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi-Min Park
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Donghyoun Lee
- Department of Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
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2
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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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Poxon A, Clarfield L, Cherniak R, Page A, Po L. Delays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:21-26. [PMID: 36436806 DOI: 10.1016/j.jogc.2022.11.004] [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: 09/21/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement. METHODS A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed. RESULTS Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0-2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2-8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]). CONCLUSION This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.
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Affiliation(s)
- Amanda Poxon
- Temerty School of Medicine, University of Toronto, Toronto, ON.
| | - Lauren Clarfield
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON
| | - Rebecca Cherniak
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON
| | - Andrea Page
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON; DAN Women and Babies Program at Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Leslie Po
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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Voaklander B, Gaudet LA, Kirkland SW, Keto-Lambert D, Villa-Roel C, Rowe BH. Interventions to improve consultations in the emergency department: A systematic review. Acad Emerg Med 2022; 29:1475-1495. [PMID: 35546740 DOI: 10.1111/acem.14520] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/21/2022] [Accepted: 05/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Emergency department (ED) consultations with specialists are necessary for safe and effective patient care. Delays in the ED consultation process, however, have been shown to increase ED length of stay (LOS) and contribute to ED crowding. This review aims to describe and evaluate the effectiveness of interventions to improve the ED consultation process. METHODS Eight primary literature databases and the gray literature were searched to identify comparative studies assessing ED-based interventions to improve the specialist consultation process. Two independent reviewers identified eligible studies, assessed study quality, and extracted data. Individual or pooled meta-analysis for continuous outcomes were calculated as mean differences (MDs) with 95% confidence intervals (CIs) using a random-effects model was conducted. RESULTS Thirty-five unique comparative intervention studies were included. While the interventions varied, four common components/themes were identified including interventions to improve consultant responsiveness (n = 11), improve access to consultants in the ED (n = 9), expedite ED consultations (n = 8), and bypass ED consultations (n = 7). Studies on interventions to improve consult responsiveness consistently reported a decrease in consult response times in the intervention group with percent changes between 10% and 71%. Studies implementing interventions to improve consult responsiveness (MD -2.55, 95% CI -4.88 to -0.22) and interventions to bypass ED consultations (MD -0.99, 95% CI -1.43 to -0.56) consistently reported a decrease in ED LOS; however, heterogeneity was high (I2 = 99%). Evidence on whether any of the interventions were effective at reducing the proportion of patients consulted or subsequently admitted varied. CONCLUSIONS The various interventions impacting the consultation process were predominately successful in reducing ED LOS, with evidence suggesting that interventions improving consult responsiveness and improving access to consultants in the ED also improve consult response times. Health care providers looking to implement interventions to improve the ED consultation process should identify key areas in their setting that could be targeted.
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Affiliation(s)
- Britt Voaklander
- Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Lindsay A Gaudet
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
| | - Scott W Kirkland
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Diana Keto-Lambert
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Al Babtain I, Alraee SA, Shalhoub MM, Hijazi LO, albalawi AA, alamer M. The Impact of Acute Care Surgery Model on the Management of Acute Appendicitis and Cholecystitis: A Single-Center Study. Cureus 2022; 14:e26724. [PMID: 35967148 PMCID: PMC9363238 DOI: 10.7759/cureus.26724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 12/01/2022] Open
Abstract
Background Acute care surgery (ACS) is a novel model for the provision of emergency general surgery (GS) care. Investigating the impact of the ACS team on the management of acute emergencies can help in establishing proper management measures and improving patient care in an emergency setting. The study aims to compare the performance indicators and patient outcomes such as hospital length of stay (LOS), time to diagnosis, and operation before and after the implementation of the acute care system. Methods The study reviewed two retrospective cohorts: the pre-ACS system (n = 202) from January 2012 to December 2013 and the post-ACS system (n = 188) from January 2014 to December 2015, which were done in a tertiary care center. All adult patients diagnosed with acute appendicitis and cholecystitis requiring emergency surgery were included. Results There was an improvement in the time interval between GS referral to the diagnosis of acute appendicitis and cholecystitis (p = 0.07) and from diagnosis to the start of the operation (p = 0.38). Patients in the post-ACS model had a shorter hospital stay than the pre-ACS model patients with [M = 3.69 SD(3.18) days versus M = 3.57 SD (3.60) days, p = 0.25]. Time from the emergency department arrival to GS referral did not show an improvement [M = 4.36 SD(3.34)] hours in the pre-ACS model versus [M = 4.53 SD(3.98)] hours in the ACS model, p = 0.86). Conclusion The ACS model led to earlier diagnosis of acute appendectomy and cholecystectomy cases and reduced the LOS. The introduction of the ACS model in Saudi Arabia showed improvement in patient care during acute emergencies. Further studies including multiple centers with larger sample sizes and longer review periods are needed to evaluate the efficiency and cost-effectiveness of the ACS model.
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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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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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8
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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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9
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Fazzalari A, Srinivas S, Panjwani S, Pozzi N, Friedrich A, Sheoran R, Sabato J, Durocher D, Reznek M, Aiello F, Litwin D, Cahan MA. A Fast-track Pathway for Emergency General Surgery at an Academic Medical Center. J Surg Res 2021; 267:1-8. [PMID: 34116389 DOI: 10.1016/j.jss.2021.04.012] [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: 08/28/2020] [Revised: 04/07/2021] [Accepted: 04/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fast Track Pathways (FTP) directed at reducing length of stay (LOS) and overall costs are being increasingly implemented for emergency surgeries. The purpose of this study is to evaluate implementation of a FTP for Emergency General Surgery (EGS) at an academic medical center (AMC). METHODS The study included 165 patients at an AMC between 2016 and 2018 who underwent laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), or laparoscopic inguinal hernia repair (LI). The FTP group enrolled 89 patients, and 76 controls prior to FTP implementation were evaluated. Time to surgery (TTS), LOS, and post-operative LOS between groups were compared. Direct costs, reimbursements, and patient reported satisfaction (satisfaction 1 = never, 4 = always) were also studied. RESULTS The sample was 60.6% female, with a median age of 40 years. Case distribution differed slightly (56.2% versus 42.1% LA, 40.4% versus 57.9% LC, FTP versus control), but TTS was similar between groups (11h39min versus 10h02min, P = 0.633). LOS was significantly shorter in the FTP group (15h17min versus 29h09min, P < 0.001), reflected by shorter post-operative LOS (3h11min versus 20h10min, P< 0.001), fewer patients requiring a hospital bed and overnight stay (P < 0.001). Direct costs were significantly lower in the FTP group, reimbursements were similar (P < 0.001 and P = 0.999 respectively), and average patient reported satisfaction was good (3.3/4). CONCLUSION In an era focused on decreasing cost, optimizing resources, and ensuring patient satisfaction, a FTP can play a significant role in EGS. At an AMC, an EGS FTP significantly decreased LOS, hospital bed utilization while not impacting reimbursement or patient satisfaction.
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Affiliation(s)
- Amanda Fazzalari
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts; The Stanley J. Dudrick Department of Surgery, Saint Mary's Hospital, Waterbury, Connecticut
| | - Shruthi Srinivas
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Suraj Panjwani
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts; The Stanley J. Dudrick Department of Surgery, Saint Mary's Hospital, Waterbury, Connecticut
| | - Natalie Pozzi
- The Stanley J. Dudrick Department of Surgery, Saint Mary's Hospital, Waterbury, Connecticut
| | - Ann Friedrich
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Reeti Sheoran
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Joseph Sabato
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Dawn Durocher
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Martin Reznek
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesco Aiello
- Department of Vascular Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Demetrius Litwin
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Mitchell A Cahan
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts.
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10
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van der Wee MJL, van der Wilden G, Hoencamp R. Acute Care Surgery Models Worldwide: A Systematic Review. World J Surg 2021; 44:2622-2637. [PMID: 32377860 PMCID: PMC7326827 DOI: 10.1007/s00268-020-05536-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background The Acute Care Surgery (ACS) model was developed as a dedicated service for the provision of 24/7 nontrauma emergency surgical care. This systematic review investigated which components are essential in an ACS model and the state of implementation of ACS models worldwide. Methods A literature search was conducted using PubMed, MEDLINE, EMBASE, Cochrane library, and Web of Science databases. All relevant data of ACS models were extracted from included articles. Results The search identified 62 articles describing ACS models in 13 countries. The majority consist of a dedicated nontrauma emergency surgical service, with daytime on-site attending coverage (cleared from elective duties), and 24/7 in-house resident coverage. Emergency department coverage and operating room access varied widely. Critical care is fully embedded in the original US model as part of the acute care chain (ACC), but is still a separate unit in most other countries. While in most European countries, ACS is not a recognized specialty yet, there is a tendency toward more structured acute care. Conclusions Large national and international heterogeneity exists in the structure and components of the ACS model. Critical care is still a separate component in most systems, although it is an essential part of the ACC to provide the best pre-, intra- and postoperative care of the physiologically deranged patient. Universal acceptance of one global ACS model seems challenging; however, a global consensus on essential components would benefit any healthcare system.
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Affiliation(s)
- Mats J L van der Wee
- Alrijne Hospital, Leiderdorp, The Netherlands. .,Leiden University Medical Center, Leiden, The Netherlands.
| | - Gwendolyn van der Wilden
- Alrijne Hospital, Leiderdorp, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands
| | - Rigo Hoencamp
- Alrijne Hospital, Leiderdorp, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands.,Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.,Erasmus University Medical Center, Rotterdam, The Netherlands
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11
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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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Kulvatunyou N, Zimmerman SA, Adhikhari S, Joseph B, Gries L, Tang AL, Rhee P. The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis. J Surg Res 2020; 260:293-299. [PMID: 33360754 DOI: 10.1016/j.jss.2020.11.018] [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: 03/11/2020] [Revised: 10/05/2020] [Accepted: 11/01/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. METHODS FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. RESULTS During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. CONCLUSIONS In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.
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Affiliation(s)
- Narong Kulvatunyou
- Division of Acute Care Surgery, Department of Surgery, Banner-University of Arizona, Tucson, Arizona.
| | - S Anthony Zimmerman
- Division of Acute Care Surgery, Department of Surgery, Banner-University of Arizona, Tucson, Arizona
| | - Srikar Adhikhari
- Department of Emergency Medicine, Banner-University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Acute Care Surgery, Department of Surgery, Banner-University of Arizona, Tucson, Arizona
| | - Lynn Gries
- Division of Acute Care Surgery, Department of Surgery, Banner-University of Arizona, Tucson, Arizona
| | - Andrew L Tang
- Division of Acute Care Surgery, Department of Surgery, Banner-University of Arizona, Tucson, Arizona
| | - Peter Rhee
- Grady Memorial Hospital, Atlanta, Georgia
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Santry HP, Strassels SA, Ingraham AM, Oslock WM, Ricci KB, Paredes AZ, Heh VK, Baselice HE, Rushing AP, Diaz A, Daniel VT, Ayturk MD, Kiefe CI. Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach. BMC Med Res Methodol 2020; 20:247. [PMID: 33008294 PMCID: PMC7532630 DOI: 10.1186/s12874-020-01096-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).
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Affiliation(s)
- Heena P. Santry
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 614, Columbus, OH 43210 USA
| | - Scott A. Strassels
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Angela M. Ingraham
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, Madison, WI USA
| | - Wendelyn M. Oslock
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Kevin B. Ricci
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Anghela Z. Paredes
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Victor K. Heh
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Holly E. Baselice
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Amy P. Rushing
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Adrian Diaz
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Vijaya T. Daniel
- Department of Surgery, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - M. Didem Ayturk
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - Catarina I. Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
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Le TQ, Chandra V, Afrin K, Srivatsa S, Bukkapatnam S. A Dynamic Systems Approach for Detecting and Localizing of Infarct-Related Artery in Acute Myocardial Infarction Using Compressed Paper-Based Electrocardiogram (ECG). SENSORS (BASEL, SWITZERLAND) 2020; 20:E3975. [PMID: 32708959 PMCID: PMC7412042 DOI: 10.3390/s20143975] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 01/17/2023]
Abstract
Timely evaluation and reperfusion have improved the myocardial salvage and the subsequent recovery rate of the patients hospitalized with acute myocardial infarction (MI). Long waiting time and time-consuming procedures of in-hospital diagnostic testing severely affect the timeliness. We present a Poincare pattern ensemble-based method with the consideration of multi-correlated non-stationary stochastic system dynamics to localize the infarct-related artery (IRA) in acute MI by fully harnessing information from paper-based Electrocardiogram (ECG). The vectorcardiogram (VCG) diagnostic features extracted from only 2.5-s long paper ECG recordings were used to hierarchically localize the IRA-not mere localization of the infarcted cardiac tissues-in acute MI. Paper ECG records and angiograms of 106 acute MI patients collected at the Heart Artery and Vein Center at Fresno California and the 12-lead ECG signals from the Physionet PTB online database were employed to validate the proposed approach. We reported the overall accuracies of 97.41% for healthy control (HC) vs. MI, 89.41 ± 9.89 for left and right culprit arteries vs. others, 88.2 ± 11.6 for left main arteries vs. right-coronary-ascending (RCA) and 93.67 ± 4.89 for left-anterior-descending (LAD) vs. left-circumflex (LCX). The IRA localization from paper ECG can be used to timely triage the patients with acute coronary syndromes to the percutaneous coronary intervention facilities.
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Affiliation(s)
- Trung Q. Le
- Industrial and Manufacturing Engineering, North Dakota State University, Fargo, ND 58102, USA
| | - Vibhuthi Chandra
- Industrial and Systems Engineering, Texas A&M University, College Station, TX 77843, USA; (V.C.); (K.A.); (S.B.)
| | - Kahkashan Afrin
- Industrial and Systems Engineering, Texas A&M University, College Station, TX 77843, USA; (V.C.); (K.A.); (S.B.)
| | - Sanjay Srivatsa
- Heart Artery and Vein Center of Fresno, Fresno, CA 93722, USA;
| | - Satish Bukkapatnam
- Industrial and Systems Engineering, Texas A&M University, College Station, TX 77843, USA; (V.C.); (K.A.); (S.B.)
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Vergis A, Metcalfe J, Stogryn SE, Clouston K, Hardy K. Impact of acute care surgery on timeliness of care and patient outcomes: a systematic review of the literature. Can J Surg 2020; 62:281-288. [PMID: 31148441 DOI: 10.1503/cjs.010718] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Dedicated emergency general surgery (EGS) service models were developed to improve efficiency of care and patient outcomes. The degree to which the EGS model delivers these benefits is debated. We performed a systematic review of the literature to identify whether the EGS service model is associated with greater efficiency and improved outcomes compared to the traditional model. Methods We searched MEDLINE, Embase, Scopus and Web of Science (Core Collection) databases from their earliest date of coverage through March 2017. Primary outcomes for efficiency of care were surgical response time, time to operation and total length of stay in hospital. The primary outcome for evaluating patient outcomes was total complication rate. Results The EGS service model generally improved efficiency of care and patient outcomes, but the outcome variables reported in the literature varied. Conclusion Development of standardized metrics and comprehensive EGS databases would support quality control and performance improvement in EGS systems.
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Affiliation(s)
- Ashley Vergis
- From the Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Vergis, Metcalfe, Stogryn, Clouston, Hardy); and St. Boniface Hospital, Winnipeg, Man. (Vergis, Clouston, Hardy)
| | - Jennifer Metcalfe
- From the Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Vergis, Metcalfe, Stogryn, Clouston, Hardy); and St. Boniface Hospital, Winnipeg, Man. (Vergis, Clouston, Hardy)
| | - Shannon E. Stogryn
- From the Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Vergis, Metcalfe, Stogryn, Clouston, Hardy); and St. Boniface Hospital, Winnipeg, Man. (Vergis, Clouston, Hardy)
| | - Kathleen Clouston
- From the Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Vergis, Metcalfe, Stogryn, Clouston, Hardy); and St. Boniface Hospital, Winnipeg, Man. (Vergis, Clouston, Hardy)
| | - Krista Hardy
- From the Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man. (Vergis, Metcalfe, Stogryn, Clouston, Hardy); and St. Boniface Hospital, Winnipeg, Man. (Vergis, Clouston, Hardy)
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Kirubarajan A, Buckley R, Khan S, Richard R, Stefanova V, Golda N. Implementing and evaluating the efficacy of an acute care urology model of care in a large community hospital. Can Urol Assoc J 2020; 14:259-264. [PMID: 32209212 DOI: 10.5489/cuaj.6371] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We implemented an acute care urology (ACU) model at a large Canadian community hospital to determine the impacts on safe and timely care of patients with renal colic. The model includes a dedicated ACU surgeon, a clinic for emergency department (ED) referrals, and additional daytime operating room (OR) blocks for urgent cases. METHODS We conducted a chart review of 579 patients presenting to the ED with renal colic. Data was collected before (pre-intervention, September to November 2015) and after (post-intervention, September to November 2016) implementation of the ACU model. Secondary methods of evaluation included surveying patients and 20 ED physicians to capture subjective feedback. RESULTS Of the 579 patients presenting with renal colic,194 were diagnosed with an obstructing kidney stone and were referred to urology for outpatient care. The ED-to-clinic time was significantly lower for those in the ACU model (p<0.001). Furthermore, the ACU clinic resulted in significantly more patients being referred for outpatient care (p=0.0004). There was also higher likelihood that patients would successfully obtain an appointment post-referral (p=0.0242). The number of after-hours and weekend surgeries decreased significantly after dedicated ACU daytime OR blocks were added in September 2015 (p<0.0001). All surveyed patients rated the care as either "excellent" or "very good," and all physicians believed the ACU model has improved patient care. CONCLUSIONS The ACU model has shown benefit in ensuring timely followup for ED patients, reducing use of after-hour OR time, and improving patient and physician satisfaction.
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Affiliation(s)
| | | | - Shawn Khan
- University of Toronto, Toronto, ON, Canada
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17
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Rasouli HR, Aliakbar Esfahani A, Abbasi Farajzadeh M. Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study. BMC Emerg Med 2019; 19:62. [PMID: 31666023 PMCID: PMC6822347 DOI: 10.1186/s12873-019-0275-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Emergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals. Methods Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase. Results Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized. Conclusion ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.
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Affiliation(s)
- Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
| | - Ali Aliakbar Esfahani
- Marine Medicine Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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18
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Panagiotopoulou IG, Bennett JMH, Tweedle EM, Di Saverio S, Gourgiotis S, Hardwick RH, Wheeler JMD, Justin Davies R. Enhancing the emergency general surgical service: an example of the aggregation of marginal gains. Ann R Coll Surg Engl 2019; 101:479-486. [PMID: 31155901 PMCID: PMC6667960 DOI: 10.1308/rcsann.2019.0061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We aimed to enhance the emergency general surgical service in our high-volume centre in order to reduce four-hour target breaches, to expedite senior decision making and to avoid unnecessary admissions. MATERIALS AND METHODS The aggregation of marginal gains theory was applied. A dual consultant on-call system was established by the incremental employment of five emergency general surgeons with a specialist interest in colorectal or oesophagogastric surgery. A surgical ambulatory care unit, which combines consultant-led clinical review with dedicated next-day radiology slots, and a dedicated working week half-day gastrointestinal urgent theatre session were instituted to facilitate ambulatory care pathways. RESULTS The presence of two consultant surgeons being on call during weekday working hours decreased the four-hour target breaches and allowed consultant presence in the surgical ambulatory care clinic and the gastrointestinal urgent theatre list. Of 1371 surgical ambulatory care clinic appointments within 30 months, 1135 (82.7%) avoided a hospital admission, corresponding to savings of £309,752 . The coordinated functioning of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list resulted in statistically significantly reduced hospital stays for patients operated for abscess drainage (gastrointestinal urgent theatre median 11 hours (interquartile range 3, 38) compared with emergency median 31 hours (interquartile range 24, 53), P < 0.001) or diagnostic laparoscopy/appendicectomy (gastrointestinal urgent theatre median 52 hours (interquartile range 41, 71) compared with emergency median 61 hours (interquartile range 43, 99), P = 0.005). Overnight surgery was reduced with only surgery that was absolutely necessary occurring out of hours. CONCLUSION The expansion of the 'traditional' on-call surgical team, the establishment of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list led to marginal gains with a reduction in unnecessary inpatient stays, expedited decision making and improved financial efficiency.
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Affiliation(s)
- IG Panagiotopoulou
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - JMH Bennett
- Oesophagogastric Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - EM Tweedle
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Di Saverio
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Gourgiotis
- Oesophagogastric Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - RH Hardwick
- Oesophagogastric Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - JMD Wheeler
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Hardy K, Metcalfe J, Clouston K, Vergis A. The Impact of an Acute Care Surgical Service on the Quality and Efficiency of Care Outcome Indicators for Patients with General Surgical Emergencies. Cureus 2019; 11:e5036. [PMID: 31501728 PMCID: PMC6721875 DOI: 10.7759/cureus.5036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Acute care surgery (ACS) models address high volumes of emergency general surgery and emergency room (ER) overcrowding. The impact of ACS service model implementation on the quality and efficiency of care (EOC) outcomes in acute appendicitis (AA) and acute cholecystitis (AC) cohorts was evaluated. Methods A retrospective chart review (N=1,229) of adult AA and AC patients admitted prior to (pre-ACS; n=507; three hospitals; 2007) and after regionalization (R-ACS; n=722; one hospital; 2011). Results R-ACS time to ER physician assessment was significantly longer for AA (3.4 ± 2.3 versus 2.4 ± 2.6 hr; p ≤ 0.001). Surgical response times (1.3 ± 1.2 vs 2.6 ± 4.3 hr for AA; 1.8 ± 1.5 vs 4.1 ± 5.0 hr for AC; p ≤ 0.0001) and acquisition of imaging (4.1 ± 4.1 vs 6.9 ± 9.9 hr for AA, p ≤ 0.0001; 7.8 ± 1.9 vs 13.2 ± 18.5 hr for AC, p ≤ 0.008) occurred significantly faster with R-ACS. R-ACS resulted in a significant increase in night-time appendectomies (21.7% vs 11.1%; p ≤ 0.002), perforated appendices (29.1 % vs 18.9 %; p ≤ 0.006), 30-day readmissions (4.56% vs 0.82%; p ≤ 0.01), and lower rate of intraoperative complications for AC patients (2.78% vs 7.69%; p ≤ 0.02). Conclusions Despite the increased volume of patients seen with the implementation of R-ACS, surgical assessments and diagnostic imaging were significantly more prompt. EOC measures were maintained. Worse AA outcomes highlight areas for improvement in delivering R-ACS.
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Affiliation(s)
- Krista Hardy
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
| | - Jennifer Metcalfe
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
| | - Kathleen Clouston
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
| | - Ashley Vergis
- Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, CAN
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Ricci KB, Rushing AP, Ingraham AM, Daniel VT, Paredes AZ, Diaz A, Heh VK, Baselice HE, Oslock WM, Strassels SA, Santry HP. The association between self-declared acute care surgery services and operating room access: Results from a national survey. J Trauma Acute Care Surg 2019; 87:898-906. [PMID: 31205221 DOI: 10.1097/ta.0000000000002394] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Timely access to the operating room (OR) for emergency general surgery (EGS) diseases is key to optimizing outcomes. We conducted a national survey on EGS structures and processes to examine if implementation of acute care surgery (ACS) would improve OR accessibility compared with a traditional general surgeon on call (GSOC) approach. METHODS We surveyed 2,811 acute care general hospitals in the United States capable of EGS care. The questionnaire included queries regarding structures and processes related to OR access and on the model of EGS care (ACS vs. GSOC). Associations between the EGS care model and structures and processes to ensure OR access were measured using univariate and multivariate models (adjusted for hospital characteristics). RESULTS Of 1,690 survey respondents (60.1%), 1,497 reported ACS or GSOC. 272 (18.2%) utilized an ACS model. The ACS hospitals were more likely to have more than 5 days of block time and a tiered system of booking urgent/emergent cases compared with GSOC hospitals (34.2% vs. 7.4% and 85.3% vs. 57.6%, respectively; all p values <0.001). Surgeons at ACS hospitals were more likely to be free of competing clinical duties, be in-house overnight, and cover at a single hospital overnight when covering EGS (40.1% vs. 4.7%, 64.7% vs. 25.6%, and 84.9% vs. 64.9%, respectively; all p values <0.001). The ACS hospitals were more likely to have overnight in-house scrub techs, OR nurses, and recovery room nurses (69.9% vs. 13.8%, 70.6% vs. 13.9%, and 45.6% vs. 5.4%, respectively; all p values <0.001). On multivariable analysis, ACS hospitals had higher odds of all structures and processes that would improve OR access. CONCLUSION The ACS implementation is associated with factors that may improve OR access. This finding has implications for potential expansion of EGS care models that ensure prompt OR access for the EGS diseases that warrant emergency surgery. LEVEL OF EVIDENCE Therapeutic, Level III.
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Affiliation(s)
- Kevin B Ricci
- From the Department of Surgery (K.B.R., A.P.R., A.Z.P., A.D., V.K.H., H.E.B., W.M.O., S.A.S., H.P.S.), Center for Surgical Health Assessment, Research and Policy (SHARP) (K.B.R., A.P.R., A.D., V.K.H., H.E.B., W.M.O., S.A.S., H.P.S.), Ohio State Wexner Medical Center, Columbus, Ohio; Department of Surgery (A.M.I.), University of Wisconsin, Madison, Wisconsin; Department of Surgery (V.T.D.), University of Massachusetts Medical School, Worcester, Massachusetts; and Ohio State University College of Medicine (W.M.O.), Columbus, Ohio
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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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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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Khubchandani JA, Ingraham AM, Daniel VT, Ayturk D, Kiefe CI, Santry HP. Geographic Diffusion and Implementation of Acute Care Surgery: An Uneven Solution to the National Emergency General Surgery Crisis. JAMA Surg 2018; 153:150-159. [PMID: 28979986 PMCID: PMC5838713 DOI: 10.1001/jamasurg.2017.3799] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/25/2017] [Indexed: 01/14/2023]
Abstract
Importance Owing to lack of adequate emergency care infrastructure and decline in general surgery workforce, the United States faces a crisis in access to emergency general surgery (EGS) care. Acute care surgery (ACS), an organized system of trauma, general surgery, and critical care, is a proposed solution; however, ACS diffusion remains poorly understood. Objective To investigate geographic diffusion of ACS models of care and characterize the communities in which ACS implementation is lagging. Design, Setting, and Participants A national survey on EGS practices was developed, tested, and administered at all 2811 US acute care hospitals providing EGS to adults between August 2015 and October 2015. Surgeons responsible for EGS coverage at these hospitals were approached. If these surgeons failed to respond to the initial survey implementation, secondary surgeons or chief medical officers at hospitals with only 1 general surgeon were approached. Interventions Survey responses on ACS implementation were linked with geocoded hospital data and national census data to determine geographic diffusion of and access to ACS. Main Outcomes and Measures We measured the distribution of hospitals with ACS models of care vs those without over time (diffusion) and by US counties characterized by sociodemographic characteristics of county residents (access). Results Survey response rate was 60% (n = 1690); 272 responding hospitals had implemented ACS by 2015, steadily increasing from 34 in 2001 to 125 in 2010. Acute care surgery implementation has not been uniform. Rural regions have limited ACS access, with hospitals in counties with greater than the 75th percentile population having 5.4 times higher odds (95% CI, 1.66-7.35) of implementing ACS than hospitals in counties with less than 25th percentile population. Communities with greater percentages of adults without a college degree also have limited ACS access (OR, 3.43; 95% CI, 1.81-6.48). However, incorporating EGS into ACS models may be a potential equalizer for poor, black, and Hispanic communities. Conclusions and Relevance Understanding and addressing gaps in ACS implementation across communities will be crucial to ensuring health equity for US residents experiencing general surgery emergencies.
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Affiliation(s)
| | | | - Vijaya T. Daniel
- University of Massachusetts Medical School, Department of Surgery, Worcester
| | - Didem Ayturk
- University of Massachusetts Medical School, Department of Surgery, Worcester
| | - Catarina I. Kiefe
- University of Massachusetts Medical School, Department of Quantitative Health Sciences, Worcester
| | - Heena P. Santry
- University of Massachusetts Medical School, Department of Surgery, Worcester
- University of Massachusetts Medical School, Department of Quantitative Health Sciences, Worcester
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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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Lee PA, Rowe BH, Innes G, Grafstein E, Vilneff R, Wang D, van Rheenen S, Lang E. Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency. CAN J EMERG MED 2018; 16:185-92. [PMID: 24852581 DOI: 10.2310/8000.2013.130973] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Requests for specialty consultation are common in emergency departments (EDs) and often contribute to delays in throughput. Our objectives were to describe the contribution of the consultation process to total ED length of stay (LOS) through novel metrics and illustrate causes of delay. METHODS We conducted a prospective cross-sectional study at three Canadian tertiary care centres. Adult ED patients with requested medical/surgical consultations were enrolled. We created original metric intervals: total consultation time (TCT) defined as the interval from the initial consultation request to the disposition decision, consult response time (CRT) from the request to the consultant arrival, and decision-making interval (DMI) from arrival to the disposition decision. The consultation impact index (CII) was defined as the percentage of ED LOS consumed by the TCT. Reasons for delay were documented if time stamps exceeded preset benchmarks. RESULTS The median TCT for 285 patients was 138 minutes (interquartile range [IQR]: 82-239 minutes), whereas the median total ED LOS was 778 minutes (IQR 485-1,274 minutes). The median CRT was 55 minutes (IQR 21-115 minutes), and the median DMI was 58 minutes (IQR 25-126 minutes). The CII measured 26% (95% CI 23-28). Major contributors to consultation delay included urgent ward issues, simultaneous ED consultations, and the need for additional laboratory or radiographic investigations. CONCLUSION The consultation process is highly variable and has an important impact on ED LOS. We describe novel measures related to consultation performance and provide an analysis of what causes delays. These results can be used to seek improvements in the consulting process.
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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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Acute care surgery and emergency general surgery: Addition by subtraction. J Trauma Acute Care Surg 2017; 81:131-6. [PMID: 26891159 DOI: 10.1097/ta.0000000000001016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The formation of Acute Care Surgery services leads to decreased time to treatment and improved outcomes for emergency general surgery (EGS) patients. However, minimal work has focused on the ideal care delivery system and team structure. We hypothesize that the implementation of a dedicated EGS team (separate from trauma and surgical critical care), with EGS-specific protocols and dedicated operating room (OR) time, will increase productivity and improve mortality. METHODS This is a retrospective review of financial and EGS registry data from fiscal year (FY) 12 to FY15. Data are from an academic, university-based EGS team composed of two acute care surgery attending surgeons, advanced practitioners (APs), residents, and a fellow. In FY12, processes were implemented to standardize paging of consults, patient sign-out with attending surgeons' and APs' participation, clinical/billing protocols, OR availability, and quality improvement. Outcomes included relative value units (RVUs), surgical case volume, charges/payments, and number of patient encounters. The secondary outcome was mortality. The χ test was used to compare mortality, and p < 0.05 was considered significant. RESULTS Total patient encounters increased from 6,723 in FY 12 to 9,238 in FY 15 (+37%). Relative value units increased from 18,422 in FY 12 to 25,314 in FY 15 (+37%). Charges increased by 76% and payments increased by 60% from FY 12 to FY 15. Charges per encounter increased from $461 in FY 12 to $591 in FY 15 (+28%) Additionally, both inpatient and surgical case loads increased. Mortality remained stable throughout the study period (FY 12, 4.5%; FY 13, 5.2%; FY 14, 5.3%; FY 15, 3.2%: p = 0.177). CONCLUSIONS Implementation of dedicated OR time, defined EGS team structure, practice protocols, and active attending surgeons'/APs' participation was temporally related to increased case volume, patients seen, and revenue, while mortality remained unchanged. Further study is necessary to establish the translatability of these data to other systems. LEVEL OF EVIDENCE Economic/decision, level III.
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Factors associated with failure of emergency wait-time targets for high acuity discharges and intensive care unit admissions. CAN J EMERG MED 2017; 20:112-124. [DOI: 10.1017/cem.2017.16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjectiveOntario established emergency department length-of-stay (EDLOS) targets but has difficulty achieving them. We sought to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions.MethodsThis was a retrospective, observational study of 2012 Sunnybrook Hospital emergency department data. The main outcome measure was failing to meet government EDLOS targets for high acuity discharges and ICU emergency admissions. The secondary outcome measures examined factors for low acuity discharges and all admissions, as well as a run chart for 2015 – 2016 ICU admissions. Multiple logistic regression models were created for admissions, ICU admissions, and low and high acuity discharges. Predictor variables were at the patient level from emergency department registries.ResultsFor discharged high acuity patients, factors predicting EDLOS target failure were having physician initial assessment duration (PIAD)>2 hours (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), magnetic resonance imaging (MRI) (OR 19.33 [12.94-28.87]), computed tomography (CT) (OR 4.24 [3.92-4.59]), and ultrasound (US) (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were bed request duration (BRD)>6 hours (OR 364.27 [43.20-3071.30]) and access block (AB)>1 hour (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4-hour target were PIAD>2 hours (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10-31.22]), MRI (OR 31.68 [6.03-166.54]), CT (OR 16.48 [10.07-26.98]), and troponin I (OR 13.37 [6.30-28.37]).ConclusionSunnybrook factors predicting failure of targets for high acuity discharges and ICU admissions were hospital-controlled. Hospitals should individualize their approach to shortening EDLOS by analysing its patient population and resource demands.
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Song MJ, Lee KM, Kim IB, Ha HK, Kim WS, Moon HJ, Jeong JH, Choi KK. Acute Care Surgery Model for Emergency Cholecystectomy. JOURNAL OF ACUTE CARE SURGERY 2016. [DOI: 10.17479/jacs.2016.6.2.57] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Myoung Je Song
- Department of Emergency Medicine, Seonam University Myongji Hospital, Goyang, Korea
| | - Kyoung Mi Lee
- Department of Emergency Medicine, Seonam University Myongji Hospital, Goyang, Korea
| | - In Byung Kim
- Department of Emergency Medicine, Seonam University Myongji Hospital, Goyang, Korea
| | - Heon-Kyun Ha
- Department of Surgery, Seonam University Myongji Hospital, Goyang, Korea
| | - Wan Sung Kim
- Department of Surgery, Seonam University Myongji Hospital, Goyang, Korea
| | - Hyoun Jong Moon
- Department of Surgery, Seonam University Myongji Hospital, Goyang, Korea
| | - Jin Ho Jeong
- Department of Surgery, Seonam University Myongji Hospital, Goyang, Korea
| | - Kang Kook Choi
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
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Chipman JG, Rosengart MR, Issa N, O'Neill PJ, Upperman JS. Surgical Infection Society Curriculum Development Symposium: An Overview. Surg Infect (Larchmt) 2016; 17:665-674. [PMID: 27635470 DOI: 10.1089/sur.2016.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Hospital-acquired infections, sepsis, and critically ill patients cost the healthcare system billions of dollars every year. Many factors contribute to these problems, and the remedies are multifactorial. Education is an important component in resolving many of the issues related to better combating the economic, social, and personal costs associated with surgical infections. The Surgical Infection Society (SIS) convened a symposium to begin a dialogue on how the SIS can facilitate a better understanding of how to educate the surgical infection professionals and trainees. The following report summarizes the presentations and commentary presented at the 2013 Annual Meeting.
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Affiliation(s)
- Jeffrey G Chipman
- 1 Department of Surgery, University of Minnesota , Minneapolis, Minnesota
| | - Matthew R Rosengart
- 2 Department of General Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Nabil Issa
- 3 Department of Surgery, Northwestern University , Chicago, Illinois
| | | | - Jeffrey S Upperman
- 5 Division of Pediatric Surgery, Children's Hospital Los Angeles , Los Angeles, California
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Abstract
OBJECTIVE The purpose of this study was to quantify and integrate key emergency department (ED) and radiology department workflow time intervals within the ED length of stay (LOS) for patients presenting with acute abdomen who require CT. MATERIALS AND METHODS An 11-month retrospective review was performed of all patients presenting to the ED with an acute abdomen who required abdominal CT. Nine key time points associated with ED LOS and CT workflow were collected: triage, physician assessment, CT request, porter schedule, CT start, CT complete, provision of first CT report, ED disposition decision, and physical discharge. The median and 90th percentile times for each interval were reported. RESULTS Ninety-six percent (2194/2292) of ED encounters during the study period met the inclusion criteria. The median ED LOS was 9.22 hours (90th percentile, 15.7 hours). Intervals associated with CT workflow accounted for 29% of the total LOS. Radiology turnaround time accounted for 32% of the entire CT workflow interval. Timeline analysis found three unique patterns of ED disposition: disposition after initial imaging report, disposition before report, and disposition before CT. CONCLUSION To our knowledge, this study is the first to quantify the contribution of CT-related workflow time intervals within the context of ED LOS. We have shown that patients do not have identical ED transit pathways, and this may under- or overestimate time interval calculations. These results show the importance of site-specific ED LOS timeline analysis to identify potential targets for quality improvement and serve as baseline targets for measuring future quality improvement initiatives.
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Diaz R, Behr J, Kumar S, Britton B. MODELING CHRONIC DISEASE PATIENT FLOWS DIVERTED FROM EMERGENCY DEPARTMENTS TO PATIENT-CENTERED MEDICAL HOMES. IIE TRANSACTIONS ON HEALTHCARE SYSTEMS ENGINEERING 2016; 5:268-285. [PMID: 26770663 PMCID: PMC4709841 DOI: 10.1080/19488300.2015.1095824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chronic Disease is defined as a long lasting health condition, which can develop and/or worsen over an extended time, but which can also be controlled. The monetary and budgetary toll due to its persistent nature has become unsustainable and requires pressing actions to limit their incidence and burden. This paper demonstrates the utility of the System Dynamics approach to simulate the behavior of key factors involved in the implementation of chronic disease management. We model the patient flow diversion from emergency departments (ED) to patient-centered medical homes (PCMH), with emphasis on the visit rates, as well as the effect of insurance coverage, in an effort to assure continuity of quality care for Asthma patients at lower costs. The model is used as an evaluative method to identify conditions of a maintained health status through adequate policy planning, in terms of resources and capacity. This approach gives decision makers the ability to track the level of implementation of the intervention and generate knowledge about dynamics between population demands and the intervention effectiveness. The functionality of the model is demonstrated through the consideration of hypothetical scenarios executed using sensitivity analysis.
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Affiliation(s)
- Rafael Diaz
- Old Dominion University, Virginia Modeling, Analysis, and Simulation Center, Norfolk, United States
| | - Joshua Behr
- Old Dominion University, Virginia Modeling, Analysis, and Simulation Center, Suffolk, 23435 United States
| | - Sameer Kumar
- University of St. Thomas, Minneapolis, United States
| | - Bruce Britton
- Eastern Virginia Medical School, Norfolk, United States
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Shakerian R, Thomson BN, Gorelik A, Hayes IP, Skandarajah AR. Outcomes in emergency general surgery following the introduction of a consultant-led unit. Br J Surg 2015; 102:1726-32. [PMID: 26492418 DOI: 10.1002/bjs.9954] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/05/2015] [Accepted: 08/27/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients presenting with emergency surgical conditions place significant demands on healthcare services globally. The need to improve emergency surgical care has led to establishment of consultant-led emergency surgery units. The aim of this study was to determine the effect of a changed model of service on outcomes. METHODS A retrospective observational study of all consecutive emergency general surgical admissions in 2009-2012 was performed. A 2-year time frame before and after the establishment of the emergency general surgery (EGS) service was used to determine the number of admissions and operations, emergency department and hospital length of stay, as well as complication rates. RESULTS The study included 7233 acute admissions. The EGS service managed 4468 patients (61·6 per cent increase) and performed 1804 operations (41·0 per cent increase). The most common diagnoses during the EGS period included acute appendicitis (532, 11·9 per cent), biliary disease (361, 8·1 per cent) and abdominal pain (561, 12·6 per cent). Appendicectomy (536, 29·7 per cent), cholecystectomy (239, 13·2 per cent) and laparotomy (226, 12·5 per cent) were the most commonly performed procedures. In the EGS period, time in the emergency department was reduced (from 8·0 to 6·0 h; P < 0·001), as was length of hospital stay (from 3·0 to 2·0 days; P < 0·001). The number of complications was reduced by 46·8 per cent, from 172 (6·2 per cent) to 147 (3·3 per cent) (P < 0·001), with a 53 per cent reduction in the number of deaths in the EGS period, from 29 (16·9 per cent) to seven (8 per cent) (P = 0·039). CONCLUSION The establishment of a consultant-led emergency surgical service has been associated with improved provision of care, resulting in timely management and improved clinical outcomes.
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Affiliation(s)
- R Shakerian
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - B N Thomson
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - A Gorelik
- Melbourne EpiCentre, Centre for Clinical Epidemiology, Biostatistics and Health Services Research, (University of Melbourne and Melbourne Health), The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - I P Hayes
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - A R Skandarajah
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
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Time delay to surgery for appendicitis: no difference between surgical assessment unit and emergency department. Eur J Emerg Med 2015; 24:290-294. [PMID: 26479739 DOI: 10.1097/mej.0000000000000342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In Denmark, emergency departments (EDs) are replacing acute surgical and medical units. The aim of this study was to compare the trajectory of patients undergoing surgery on the suspicion of appendicitis in a surgical assessment unit (SAU) and EDs with an observation unit, respectively. The primary outcome measure was the time from hospital arrival-to-decision for surgery. MATERIALS AND METHODS A comparative retrospective study with a cross-sectional design and a before-and-after design was carried out during January 2011 to December 2012 at a SAU and an ED at a university hospital (U-SAU and U-ED) and at an ED at a regional hospital (R-ED). Data included time of arrival, decision for surgery, surgery and discharge, and number of blood tests. RESULTS In total, 250 patients were included. Time to decision for surgery was 4.50, 4.95, and 4.63 h (P=0.58) in the U-SAU, R-ED, and U-ED, respectively. Time from decision for surgery to start of surgery was 4.60, 3.29, and 4.12 h in the U-SAU, R-ED, and U-ED, respectively. The difference was significant between the U-SAU and R-ED (P=0.05) and between R-ED and U-ED (P=0.03). Time from surgery to discharge from the hospital was 17.88, 19.28, and 15.13 h in the U-SAU, R-ED, and U-ED, respectively. The difference was significant between the EDs (P=0.02). Significantly more blood tests were performed in the EDs than in the U-SAU. CONCLUSION The introduction of EDs with observation units did not influence time to decision for surgery, but more blood tests were performed.
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The impact of acute care surgery on appendicitis outcomes: Results from a national sample of university-affiliated hospitals. J Trauma Acute Care Surg 2015. [PMID: 26218698 DOI: 10.1097/ta.0000000000000732] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute appendicitis is the most common indication for emergency general surgery (EGS) in the United States. We examined the role of acute care surgery (ACS) on interventions and outcomes for acute appendicitis at a national sample of university-affiliated hospitals. METHODS We surveyed senior surgeons responsible for EGS coverage at University HealthSystems Consortium hospitals, representing more than 90% of university-affiliated hospitals in the United States. The survey elicited data on resources allocated for EGS during 2013. Responses were linked to University HealthSystems Consortium outcomes data by unique hospital identifiers. Patients treated at hospitals reporting hybrid models for EGS coverage were excluded. Differences in interventions and outcomes between patients with acute appendicitis treated at ACS hospitals versus hospitals with a general surgeon on-call model (GSOC) were analyzed using univariate comparisons and multivariable logistic regression models adjusted for patient demographics, clinical acuity, and hospital characteristics. RESULTS We found 122 hospitals meeting criteria for analysis where 2,565 patients were treated for acute appendicitis. Forty-eight percent of hospitals had an ACS model (n = 1,414), and 52% had a GSOC model (n = 1,151). Hospitals with ACS models were more likely to treat minority patients than those with GSOC models. Patients treated at ACS hospitals were more likely to undergo laparoscopic appendectomy. In multivariable modeling of patients who had surgery (n = 2,258), patients treated at ACS hospitals had 1.86 (95% confidence interval, 1.23-2.80) greater odds of undergoing laparoscopic appendectomy. CONCLUSION In an era when laparoscopic appendectomy is increasingly accepted for treating uncomplicated acute appendicitis, particularly in low-risk patients, it is concerning that patients treated at GSOC model hospitals are more likely to undergo traditional open surgery at the time of presentation. Furthermore, hospitals with ACS are functioning as safety-net hospitals for vulnerable patients with acute appendicitis. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Wilgenbusch CS, Dust PW, Sunderland IR. Development of an Acute Care Plastic Surgery Service in the Saskatoon Health Region: Effects on flexor tendon management. Plast Surg (Oakv) 2015; 23:195-8. [PMID: 26361628 DOI: 10.4172/plastic-surgery.1000927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The acute care surgery model has gained favour in general surgery, but has yet to be widely adopted in other specialties. An Acute Care Plastic Surgery (ACS) Service was recently implemented in the Saskatoon Health Region in an effort to improve trauma care. OBJECTIVE To evaluate the impact of ACS on the management of flexor tendon lacerations. The authors hypothesize that ACS has resulted in more timely intervention, improved outcomes and decreased 'after hours' surgery. METHODS A retrospective review of patients treated for flexor tendon lacerations from 2007 to 2013 was performed. Patients were stratified into two groups based on whether they received treatment before (group A) or after (group B) ACS implementation. Variables included dates and times of patient referral, consultation and tendon repair; postoperative complications; and admissions. A surgeon survey was administered on the perceived impact of ACS. RESULTS Group A was more likely to have surgery performed after hours (P=0.0019) and be admitted to hospital (P=0.0211) compared with group B. Time from referral to consultation and injury-to-surgery interval were slightly increased post-ACS (Group B). Surgeons were highly satisfied with the new system, citing benefits to patients and surgeons. CONCLUSION ACS was designed to improve trauma care, while favourably impacting surgeon workload. Surprisingly, the injury-to-surgery interval was slightly increased. However, this was not clinically significant and did not lead to increased postoperative complications. This finding was likely due to a favourable change in practice patterns observed after ACS implementation. ACS has resulted in fewer hospital admissions, decreased after-hours surgeries and improved surgeon satisfaction.
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Affiliation(s)
- Chelsea S Wilgenbusch
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Peter W Dust
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Ian R Sunderland
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
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Wilgenbusch CS, Dust PW, Sunderland IR. Development of an Acute Care Plastic Surgery Service in the Saskatoon Health Region: Effects on flexor tendon management. Plast Surg (Oakv) 2015. [DOI: 10.1177/229255031502300305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The acute care surgery model has gained favour in general surgery, but has yet to be widely adopted in other specialties. An Acute Care Plastic Surgery (ACS) Service was recently implemented in the Saskatoon Health Region in an effort to improve trauma care. Objective To evaluate the impact of ACS on the management of flexor tendon lacerations. The authors hypothesize that ACS has resulted in more timely intervention, improved outcomes and decreased ‘after hours’ surgery. Methods A retrospective review of patients treated for flexor tendon lacerations from 2007 to 2013 was performed. Patients were stratified into two groups based on whether they received treatment before (group A) or after (group B) ACS implementation. Variables included dates and times of patient referral, consultation and tendon repair; postoperative complications; and admissions. A surgeon survey was administered on the perceived impact of ACS. Results Group A was more likely to have surgery performed after hours (P=0.0019) and be admitted to hospital (P=0.0211) compared with group B. Time from referral to consultation and injury-to-surgery interval were slightly increased post-ACS (Group B). Surgeons were highly satisfied with the new system, citing benefits to patients and surgeons. Conclusion ACS was designed to improve trauma care, while favourably impacting surgeon workload. Surprisingly, the injury-to-surgery interval was slightly increased. However, this was not clinically significant and did not lead to increased postoperative complications. This finding was likely due to a favourable change in practice patterns observed after ACS implementation. ACS has resulted in fewer hospital admissions, decreased after-hours surgeries and improved surgeon satisfaction.
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Affiliation(s)
- Chelsea S Wilgenbusch
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Peter W Dust
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Ian R Sunderland
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
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Implementation of an Acute Care Surgery Service Facilitates Modern Clinical Practice Guidelines for Gallstone Pancreatitis. J Am Coll Surg 2015; 221:975-81. [PMID: 26372635 DOI: 10.1016/j.jamcollsurg.2015.07.447] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/17/2015] [Accepted: 07/17/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Current practice guidelines for management of gallstone pancreatitis (GSP) recommend early cholecystectomy for patient stabilization and bile duct clearance, preferably at index admission. Historically, this has been difficult to achieve due to lack of emergency surgical resources. We investigated whether implementation of an acute care surgery (ACS) model would allow better adherence to current practice guidelines for GSP. STUDY DESIGN A retrospective review was conducted of all patients admitted with the diagnosis of GSP to 2 tertiary care university teaching hospitals from January 2002 to October 2013. Diagnosis was confirmed on review of clinical, biochemical, and radiographic criteria. Patients were divided into pre-ACS (2002 to 2009) and post-ACS (2010 to 2013) eras. Only 1 of the 2 hospitals implemented an ACS service in the latter era. Data were collected on demographics, admissions, cholecystectomy timing, and emergency department visits. RESULTS Before implementation of an ACS service, the rate of index cholecystectomy was 3% at both hospital sites. The rate of index cholecystectomy increased significantly with the addition of ACS, from 2.4% to 67% (p < 0.001). The presence of an ACS team was highly predictive of index cholecystectomy (odds ratio = 10.4; 95% CI 2.0 to 55.1). Patients who did not undergo cholecystectomy during the index admission had an overall readmission rate of 24.9% at both sites. In the ACS hospital, repeat emergency department visits decreased from 24.8% to 8.3% (p < 0.001) and readmission rate decreased from 16.8% to 7.3% (p = 0.04) in the pre-and post-ACS eras, respectively. CONCLUSIONS Implementation of an ACS service resulted in a higher rate of index cholecystectomy and decreased emergency department visits and readmissions for biliary disease, and allowed for increased adherence to clinical practice guidelines for GSP.
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Collins CE, Pringle PL, Santry HP. Innovation or rebranding, acute care surgery diffusion will continue. J Surg Res 2015; 197:354-62. [PMID: 25891673 DOI: 10.1016/j.jss.2015.03.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 02/11/2015] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patterns of adoption of acute care surgery (ACS) as a strategy for emergency general surgery (EGS) care are unknown. METHODS We conducted a qualitative study comprising face-to-face interviews with senior surgeons responsible for ACS at 18 teaching hospitals chosen to ensure diversity of opinions and practice environment (three practice types [community, public or charity, and university] in each of six geographic regions [Mid-Atlantic, Midwest, New England, Northeast, South, and West]). Interviews were recorded, transcribed, and analyzed using NVivo (QSR International, Melbourne, Australia). We applied the methods of investigator triangulation using an inductive approach to develop a final taxonomy of codes organized by themes related to respondents' views on the future of ACS as a strategy for EGS. We applied our findings to a conceptual model on diffusion of innovation. RESULTS We found a paradox between ACS viewed as a health care delivery innovation versus a rebranding of comprehensive general surgery. Optimism for the future of ACS because of increased desirability for trauma and critical care careers as well as improved EGS outcomes was tempered by fear over lack of continuity, poor institutional resources, and uncertainty regarding financial viability. Our analysis suggests that the implementation of ACS, whether a true health care delivery innovation or an innovative rebranding, fits into the Rogers' diffusion of innovation theory. CONCLUSIONS Despite concerns over resource allocation and the definition of the specialty, from the perspective of senior surgeons deeply entrenched in executing this care delivery model, ACS represents the new face of general surgery that will likely continue to diffuse from these early adopters.
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Affiliation(s)
- Courtney E Collins
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Patricia L Pringle
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Heena P Santry
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts.
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Variations in the implementation of acute care surgery: results from a national survey of university-affiliated hospitals. J Trauma Acute Care Surg 2015; 78:60-7; discussion 67-8. [PMID: 25539204 DOI: 10.1097/ta.0000000000000492] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To date, no studies have reported nationwide adoption of acute care surgery (ACS) or identified structural and/or process variations for the care of emergency general surgery (EGS) patients within such models. METHODS We surveyed surgeons responsible for EGS coverage at University Health Systems Consortium hospitals using an eight-page postal/e-mail questionnaire querying respondents on hospital and EGS structure/process measures. Survey responses were analyzed using descriptive statistics, univariate comparisons, and multivariable regression models. RESULTS Of 319 potential respondents, 258 (81%) completed the surveys. A total of 81 hospitals (31%) had implemented ACS, while 134 (52%) had a traditional general surgeon on-call (GSOC) model. Thirty-eight hospitals (15%) had another model (hybrid). Larger-bed, university-based, teaching hospitals with Level 1 trauma center verification status located in urban areas were more likely to have adopted ACS. In multivariable modeling, hospital type, setting, and trauma center verification predicted ACS implementation. EGS processes of care varied, with 28% of the GSOC hospitals having block time versus 67% of the ACS hospitals (p < 0.0001), 45% of the GSOC hospitals providing ICU [intensive care unit] care to EGS patients in a surgical/trauma ICU versus 93% of the ACS hospitals (p < 0.0001), 5.7 ± 3.2 surgeons sharing call at GSOC hospitals versus 7.9 ± 2.3 surgeons at ACS hospitals (p < 0.0001), and 13% of the GSOC hospitals requiring in-house EGS call versus 75% of the ACS hospitals (p < 0.0001). Among ACS hospitals, there were variations in patient cohorting (EGS patients alone, 25%; EGS + trauma, 21%; EGS + elective, 17%; and EGS + trauma + elective, 30%), data collection (26% had prospective EGS registries), patient hand-offs (56% had attending surgeon presence), and call responsibilities (averaging 4.8 ± 1.3 calls per month, with 60% providing extra call stipend and 40% with no postcall clinical duties). CONCLUSION The potential of the ACS on the national crisis in access to EGS care is not fully met. Variations in EGS processes of care among adopters of ACS suggest that standardized criteria for ACS implementation, much like trauma center verification criteria, may be beneficial.
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Nagaraja V, Eslick GD, Cox MR. The acute surgical unit model verses the traditional "on call" model: a systematic review and meta-analysis. World J Surg 2015; 38:1381-7. [PMID: 24430507 DOI: 10.1007/s00268-013-2447-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The acute surgical unit (ASU) is a novel model for the provision of emergency general surgery care. The ASU model was initially developed in New South Wales hospitals during 2005 and 2006. Several studies have analysed the effects on patient outcomes and timeliness of care for nontrauma patients presenting with acute general surgical conditions. The purpose of this study was to perform a meta-analysis to determine the efficacy of the ASU model compared with the traditional on-call model for specific conditions. METHODS A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data were extracted from each study and used to calculate a pooled odd ratio (OR) and 95 % confidence interval (CI). RESULTS The search identified 18 studies; appendectomy (n = 9), acute cholecystitis (n = 7), and small-bowel obstruction (SBO) (n = 2). In the appendectomy cohort, the proportion of appendicular perforation were similar in pre-ASU and ASU period (OR 1.02, 95 % CI 0.77-1.37, p = 0.13). The incidence of complications in the appendectomy cohort was significantly lower in the ASU group; 14.5 % pre-ASU and 10.9 % post-ASU (OR 1.649, 95 % CI 0.732-3.714, p = 0.009). The negative appendectomy rate was similar for the pre- and post-ASU groups (OR 1.07, 95 % CI 0.88-1.31, p = 0.83). Likewise the conversion rate to open surgery and total hospital stay were similar between the two groups. The proportion of night time operations reduced significantly in the ASU period (OR 1.9, 95 % CI 1.32-2.74, p = 0.001). In the acute cholecystitis cohort, the conversion rate to open surgery was significantly higher in the pre-ASU group (15.1 %) compared with the post-ASU group (7.5 %) (OR 1.879, 95 % CI 1.072-3.293, p = 0.04) The incidence of complications was higher in the pre-ASU (14 %) compared with the post-ASU (6.8 %) group (OR 2.231, 95 % CI 1.372-3.236, p = 0.03). The mean hospital stay was significantly lower in the ASU period (5.3 vs. 3.7 days, p = 0.0063). There was insufficient data available to analyse outcomes for SBO. CONCLUSIONS The ASU model provides a safe surgical environment for patients and is associated with a reduced complication rate for appendectomy and laparoscopic cholecystectomy for acute cholecystitis. There is a reduced conversion rate and a shorter length of stay for patients with acute cholecystitis. Overall, the ASU model has translated to better outcomes for patients presenting with acute general surgical conditions.
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Affiliation(s)
- Vinayak Nagaraja
- The Whiteley-Martin Research Centre, The Discipline of Surgery, Sydney Medical School, The University of Sydney, Nepean Hospital, Level 5, South Block, Penrith, NSW, 2751, Australia
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Fu CY, Huang HC, Chen RJ, Tsuo HC, Tung HJ. Implementation of the acute care surgery model provides benefits in the surgical treatment of the acute appendicitis. Am J Surg 2014; 208:794-799. [PMID: 25441600 DOI: 10.1016/j.amjsurg.2013.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/05/2013] [Accepted: 04/29/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Several reports have indicated the benefits of the acute care surgery (ACS) model in surgical outcomes. We tried to delineate the impact of the ACS model on surgical efficiency and quality. METHODS Before the ACS model was implemented, abdominal surgical emergencies were evaluated by an on-call nontrauma general surgeon (pre-ACS model). An in-house trauma surgeon treated all patients with trauma or nontrauma abdominal surgical emergencies after the ACS model. Patients with acute appendicitis who underwent appendectomies were included. We conducted a pre- and poststudy to compare the time patients were in the emergency department and surgical qualities. RESULTS There were 146 and 159 patients enrolled in the pre-ACS model and ACS model, respectively. The overall ED length of stay in the ACS model was significantly shorter than that in the pre-ACS model (300.3 ± 61.7 vs 719.1 ± 339.0 minutes, P < .001). Hospital LOS was also significantly shorter in the ACS model than in the pre-ACS model (2.44 ± 1.39 vs 3.83 ± 2.21 days, P = .022). CONCLUSION The ACS model may improve abdominal surgical efficiency and quality. Our study results echoed the benefits of the implementation of the ACS model shown in North America.
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Affiliation(s)
- Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Hung-Chang Huang
- Department of Trauma and Emergency Surgery, Taipei Medical University-Wan Fang Hospital, Taipei Medical University, No 111, Sec 3, Xinglong Rd, Taipei 11696, Taiwan
| | - Ray-Jade Chen
- Department of Trauma and Emergency Surgery, Taipei Medical University-Wan Fang Hospital, Taipei Medical University, No 111, Sec 3, Xinglong Rd, Taipei 11696, Taiwan.
| | - Hsun-Chung Tsuo
- School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Jung Tung
- School of Medicine, Taipei Medical University, Taipei, Taiwan
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Kulvatunyou N, Watt J, Friese RS, Gries L, Green DJ, Joseph B, O'Keeffe T, Tang AL, Vercruysse G, Rhee P. Management of acute mild gallstone pancreatitis under acute care surgery: should patients be admitted to the surgery or medicine service? Am J Surg 2014; 208:981-7; discussion 986-7. [PMID: 25312841 DOI: 10.1016/j.amjsurg.2014.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 09/08/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We hypothesized that patients with acute mild gallstone pancreatitis (GSP) admitted to surgery (SUR; vs medicine [MED]) had a shorter time to surgery, shorter hospital length of stay (HLOS), and lower costs. METHODS We performed chart reviews of patients who underwent a cholecystectomy for acute mild GSP from October 1, 2009 to May 31, 2013. We excluded patients with moderate to severe and non-gallstone pancreatitis. We compared outcomes for time to surgery, HLOS, costs, and complications between the 2 groups. RESULTS Fifty acute mild GSP patients were admitted to MED and 52 to SUR. MED patients were older and had more comorbidity. SUR patients had a shorter time to surgery (44 vs 80 hours; P < .001), a shorter HLOS (3 vs 5 days; P < .001), and lower hospital costs ($11,492 ± 6,480 vs $16,183 ± 12,145; P = .03). In our subgroup analysis on patients with an American Society of Anesthesiologists score between 1 and 2, the subgroups were well matched; all outcomes still favored SUR patients. CONCLUSIONS Admitting acute mild GSP patients directly to SUR shortened the time to surgery, shortened HLOS, and lowered hospital costs.
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Affiliation(s)
- Narong Kulvatunyou
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA.
| | - John Watt
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA
| | - Randall S Friese
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA
| | - Lynn Gries
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA
| | - Donald J Green
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA
| | - Bellal Joseph
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA
| | - Terence O'Keeffe
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA
| | - Andrew L Tang
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA
| | - Gary Vercruysse
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA
| | - Peter Rhee
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, Room 5411, 1501 North Campbell Avenue, PO Box 245603, Tucson, AZ 85727-5063, USA
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The public health burden of emergency general surgery in the United States. J Trauma Acute Care Surg 2014; 77:202-8. [DOI: 10.1097/ta.0000000000000362] [Citation(s) in RCA: 264] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ball CG, Dixon E, MacLean AR, Kaplan GG, Nicholson L, Sutherland FR. The impact of an acute care surgery clinical care pathway for suspected appendicitis on the use of CT in the emergency department. Can J Surg 2014; 57:194-8. [PMID: 24869612 DOI: 10.1503/cjs.019912] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The natural evolution of an acute care surgery (ACS) service is to develop disease-specific care pathways aimed at quality improvement. Our primary goal was to evaluate the implementation of an ACS pathway dedicated to suspected appendicitis on patient flow and the use of computed tomography (CT) in the emergency department (ED). METHODS All adults within a large health care system (3 hospitals) with suspected appendicitis were analyzed during our study period, which included 3 time periods: pre- and postimplementation of the disease-specific pathway and at 12-month follow-up. RESULTS Of the 1168 consultations for appendicitis that took place during our study period, 349 occurred preimplementation, 392 occurred postimplementation, and 427 were follow-up visits. In all, 877 (75%) patients were admitted to the ACS service. Overall, 83% of patients underwent surgery within 6 hours. The mean wait time from CT request to obtaining the CT scan decreased with pathway implementation at all sites (197 v. 143 min, p < 0.001). This improvement was sustained at 12-month followup (131 min, p < 0.001). The pathway increased the number of CTs completed in under 2 hours from 3% to 42% (p < 0.001). No decrease in the total number of CTs or the pattern of ultrasonography was noted (p = 0.42). Wait times from ED triage to surgery were shortened (665 min preimplementation, 633 min postimplementation, 631 min at the 12-month follow-up, p = 0.040). CONCLUSION A clinical care pathway dedicated to suspected appendicitis can decrease times to both CT scan and surgical intervention.
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Affiliation(s)
- Chad G Ball
- The Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alta
| | - Elijah Dixon
- The Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alta
| | - Anthony R MacLean
- The Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alta
| | - Gilaad G Kaplan
- The Department of Medicine, University of Calgary, Foothills Medical Centre, Calgary, Alta
| | - Lynn Nicholson
- The Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alta
| | - Francis R Sutherland
- The Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alta
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Sustainability and success of the acute care surgery model in the nontrauma setting. J Am Coll Surg 2014; 219:90-8. [PMID: 24795267 DOI: 10.1016/j.jamcollsurg.2014.02.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/27/2014] [Accepted: 02/06/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND The use of an acute care surgical model has been shown to improve patient care and efficiency. We propose that it is possible to apply this model to emergency general surgery patients at a nontrauma hospital. With this acute care surgery service, no change in the quality of care will occur, and improvements in quality, cost, and outcomes may be achieved and sustained. STUDY DESIGN A retrospective review was performed of all emergency surgery operations performed at a tertiary referral community hospital without a trauma service. Data were collected from 1 year before and each year up to 4 years after the implementation of an acute care surgical (ACS) service. RESULTS There were fewer overall complications with ACS (21% to 12%, p < 0.0001), and a shorter length of stay (6.5 days to 5.7 days, p = 0.0016). Hospital costs fell from $12,009 to $8,306 (p < 0.0001). Post-appendectomy complications decreased (13% to 3.7%, p < 0.0001), length of stay was shorter (3.0 to 2.3 days, p < 0.0001), and hospital costs decreased from $9,392 to $5,872 (p < 0.0001). Post-cholecystectomy complications decreased (21% to 9%, p = 0.012), length of stay was shorter (5.3 to 3.8 days, p = 0.0004), and hospital costs decreased from $12,526 to $9,348 (p < 0.0001). CONCLUSIONS An acute care surgery service can be successfully implemented at a nontrauma hospital. The improvements seen in outcomes and finances are sustainable over time. This sort of coordinated, consistent care is successful and allows alignment of the goals of surgeons, hospitals, and patients.
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Abstract
BACKGROUND The delivery of equitable trauma care in Canada is not without challenges within our universal health care system. Notably, the tyranny of geography is intermittently at odds with adequate access for our rural, indigenous, and impoverished populations. Other differences exist when compared with neighbouring trauma systems, for example in the United States. METHODS As a critical review, we chose to compare and critique the overall system of trauma organization and perceived societal expectations of a high-income, North American country (Canada) to assist with discussions on trauma systems for the future. RESULTS Tele-technology is providing some early solutions. Trauma systems and delivery of care in Canada differ from the United States due to our single-payer system, regionalization and universal provision. Care for injured Canadians has a long history of being multidisciplinary, with collaborative research programs. Canada also has a history of global surgical endeavours, beginning with Dr. Norman Bethune and his recognition of the political causes of trauma and continuing as a global public health concern for all. CONCLUSIONS While challenges continue to exist for the provision of equitable trauma care in Canada, unique multidisciplinary, collaborative and technology-based solutions continue to be developed, both locally and globally, to address this critical public health issue.
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Affiliation(s)
- Tanya Zakrison
- DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, 1800 NW 10th Avenue, T247, Miami, FL 33136, USA.
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Kelly ME, Conlon C, Le GN, Nason GJ, Mansour E, Conlon KC, Ridgway PF. Time to surgical review: an assessment of the traditional model of emergency surgical care. Ir J Med Sci 2014; 184:335-40. [PMID: 24719279 DOI: 10.1007/s11845-014-1113-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 03/25/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The traditional model for emergency surgical care consists of an on-call team providing service to the emergency department, while simultaneously balancing the demands of elective work. Various newer models, such as the "surgeon of the week" aim to reduce the conflict between elective and emergency duties. Despite the recent focus on newer models, there remains no data on the effectiveness of the traditional model. We aim to assess the efficacy of the traditional model in a large regional hospital. METHODS A retrospective study between July 2009 and March 2010 was performed. Primarily, we assessed the initial time to surgical consultation after emergency department referral. Secondarily, we evaluated the impact of time periods, days of week, and case-mix etiology on this consultation time. RESULTS The overall median time to surgical consultation after emergency department referral was 30 min (N = 860, P = 0.709). However, the median time to consultation was 60, 30, and 20 min for daytime, evening and night time, respectively (*P < 0.001). Trauma cases had a median time of 15 min, vascular had 45 min, neoplasm had 120 min, while other categories (upper and lower gastroenterology, and skin related) were 30 min (*P = 0.025). DISCUSSION Newer models of acute surgical care have desirable outcomes in consultation times. However, regional and economical implications have a substantial impact on which model is feasible at local levels. We demonstrated that the traditional model still remains effective in a large sized tertiary referral unit.
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Affiliation(s)
- M E Kelly
- The Adelaide and Meath Hospital -Tallaght, Trinity College Dublin, Dublin, Ireland,
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Time and cost analysis of gallbladder surgery under the acute care surgery model. J Trauma Acute Care Surg 2014; 76:710-4. [PMID: 24553538 DOI: 10.1097/ta.0000000000000117] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The acute care surgery (ACS) model has been shown to improve work flow efficiency and to reduce hospital stay. We hypothesized that, in patients with gallbladder (GB) disease who were admitted through our emergency department (ED) and then underwent surgery, the ACS model shortened the time to surgery, decreased the length of hospital stay, and reduced hospital costs. METHODS We retrospectively queried our GB surgery practice records for 2008 (before the establishment of the ACS model at our institution in 2009). We then performed time and cost comparison with our prospectively maintained GB surgery practice database for 2010. We excluded any inpatient GB surgeries and any GB surgeries that were performed for choledocholithiasis and acute pancreatitis. RESULTS Our study was composed of 94 patients from the pre-ACS period (2008) and 234 patients from the ACS period (2010). Patients' baseline characteristics were similar between the two periods, except for a higher percentage of females in the ACS period (77% vs. 66%, p = 0.04). Approximately one third of patients from both periods had acute cholecystitis. In the ACS period, the mean time to surgery, that is, from ED arrival to operating room arrival, was shorter (20.8 [13.8] hours vs. 25.7 [16.2] hours, p = 0.007); more patients underwent surgery within 24 hours after ED arrival (75% vs. 59%, p = 0.004); and more patients underwent surgery between 12:00 midnight and 7:00 AM (25% vs. 6.4%, p < 0.001). As a result, hospital length of stay was 1.4 days shorter in the ACS period, with cost saving per patient of approximately $1,000. CONCLUSION We found that implementation of ACS model led to benefits for patients who came to our ED with GB disease, including shorter time to surgery, shorter hospital stay, and decreased hospital costs. The ACS model benefits the health care system. LEVEL OF EVIDENCE Therapeutic study, level IV.
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