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Wang H, Luu V, Jiang E, Kirkland O, Kabir S, Davis SS, Hugh TJ. Evaluation of a modified emergency surgical acuity score in predicting operative and non-operative mortality and morbidity in an acute surgical unit. ANZ J Surg 2023; 93:2297-2302. [PMID: 37296520 DOI: 10.1111/ans.18564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Emergency general surgery (EGS) patients have an increased risk of mortality and morbidity compared to other surgical patients. Limited risk assessment tools exist for use in both operative and non-operative EGS patients. We assessed the accuracy of a modified Emergency Surgical Acuity Score (mESAS) in EGS patients at our institution. METHODS A retrospective cohort study from an acute surgical unit at a tertiary referral hospital was performed. Primary endpoints assessed included death before discharge, length of stay (LOS) >5 days and unplanned readmission within 28 days. Operative and non-operative patients were analysed separately. Validation was performed using the area under the receiver operating characteristic (AUROC), Brier score and Hosmer-Lemeshow test. RESULTS A total of 1763 admissions between March 2018 and June 2021 were included for analysis. The mESAS was an accurate predictor of both death before discharge (AUROC 0.979, Brier score 0.007, Hosmer-Lemeshow P = 0.981) and LOS >5 days (0.787, 0.104, and 0.253, respectively). The mESAS was less accurate in predicting readmission within 28 days (0.639, 0.040, and 0.887, respectively). The mESAS retained its predictive ability for death before discharge and LOS >5 days in the split cohort analysis. CONCLUSION This study is the first to validate a modified ESAS in a non-operatively managed EGS population internationally and the first to validate the mESAS in Australia. The mESAS accurately predicts death before discharge and prolonged LOS for all EGS patients, providing a highly useful tool for surgeons and EGS units worldwide.
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Affiliation(s)
- Hogan Wang
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Veronica Luu
- Data Analysis and Surgical Outcomes Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Eric Jiang
- Surgical Education Research and Training Institute, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Olivia Kirkland
- Acute Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Shahrir Kabir
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Acute Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Sean S Davis
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Acute Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Thomas J Hugh
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Surgical Education Research and Training Institute, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Acute Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Jones P, Haustead D, Walker K, Honan B, Gangathimmaiah V, Mitchell R, Bissett I, Forero R, Martini E, Mountain D. Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature. Emerg Med Australas 2021; 33:398-408. [PMID: 33724685 DOI: 10.1111/1742-6723.13760] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Abstract
Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.
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Affiliation(s)
- Peter Jones
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Daniel Haustead
- Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Katie Walker
- Emergency Department, Cabrini Health, Melbourne, Victoria, Australia
| | - Bridget Honan
- Central Australian Retrieval Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Vinay Gangathimmaiah
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Robert Mitchell
- Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ian Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Roberto Forero
- Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | | | - David Mountain
- Emergency Department, Sir Charles Gardner Hospital, Perth, Western Australia, Australia
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Kinnear N, Han J, Tran M, Herath M, Jolly S, Hennessey D, Dobbins C, Sammour T, Moore J. Emergency general surgery models in Australia: a cross-sectional study. AUST HEALTH REV 2020; 44:952-957. [PMID: 33203508 DOI: 10.1071/ah19260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/28/2020] [Indexed: 11/23/2022]
Abstract
Objective Emergency general surgery (EGS) patients experience superior outcomes when cared for within an acute surgical unit (ASU) model. EGS structures in most Australian hospitals remain unknown. This study aimed to describe the national spectrum of EGS models. Methods A cross-sectional study was performed of all Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). The primary outcome was the incidence of each EGS model. Secondary outcomes were the relationship of the EGS model to objective hospital variables, and qualitative reasons for the choice of model. Results Of the 120 eligible hospitals, 119 (99%) participated. Sixty-four hospitals reported using an ASU (28%) or hybrid EGS model (26%), whereas the remaining 55 (46%) used a traditional model. ASU implementation was significantly more common among hospitals of greater peer group, bed number, surgeon pool and trauma service sophistication. Leading drivers for ASU commencement were aims to improve patient care and decrease after-hours operating, whereas common barriers against uptake were insufficient EGS patient load or surgeon on-call pool. Conclusions ASU or hybrid models of care may be more widespread than currently reported. The introduction of such structures is heavily dependent on hospital and staff size, trauma subspecialisation and EGS patient throughput. What is known about the topic? Traditionally, general surgical staff were rostered to elective operating and clinic duties, with emergency patients managed on an ad hoc basis. An ASU model, with a surgeon dedicated to EGS patients, has been associated with superior outcomes. However, the Australian uptake of this model is unknown. What does this paper add? This study enrolled 119 of 120 (99%) Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). Uptake of the ASU or hybrid model was more widespread than expected, existing in 64 of 119 (54%) centres. Factors for and against ASU implementation were also assessed. What are the implications for practitioners? Hospitals considering implementing an ASU or hybrid model will be reassured by the common reports of improved patient outcomes and decreased after-hours operating. However, potential hospitals must assess the suitability of the ASU model to their surgeon pool and EGS patient load.
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Affiliation(s)
- Ned Kinnear
- Department of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia. ; ; and Corresponding author.
| | - Jennie Han
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Minh Tran
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Matheesha Herath
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Samantha Jolly
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Derek Hennessey
- Department of Urology, Mercy University Hospital, Cork, Ireland.
| | - Christopher Dobbins
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - Tarik Sammour
- Department of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia. ; ; and Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
| | - James Moore
- Department of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia. ; ; and Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. ; ; ; ;
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A systematic review of dedicated models of care for emergency urological patients. Asian J Urol 2020; 8:315-323. [PMID: 34401338 PMCID: PMC8356060 DOI: 10.1016/j.ajur.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 01/20/2020] [Accepted: 04/21/2020] [Indexed: 11/09/2022] Open
Abstract
Objective To systematically evaluate the spectrum of models providing dedicated resources for emergency urological patients (EUPs). Methods A search of Cochrane, Embase, Medline and grey literature from January 1, 2000 to March 26, 2019 was performed using methods pre-published on PROSPERO. Reporting followed Preferred Reporting Items for Systematic Review and meta-analysis guidelines. Eligible studies were articles or abstracts published in English describing dedicated models of care for EUPs, which reported at least one secondary outcome. Studies were excluded if they examined pathways dedicated only to single presentations, such as torsion, or outpatient solutions, such as rapid access clinics. The primary outcome was the spectrum of models. Secondary outcomes were time-to-theatre, length of stay, complications and cost. Results Seven studies were identified, totalling 487 patients. Six studies were conference abstracts, while one study was of full-text length but published in grey literature. Four distinct models were described. These included consultant urologists allocated solely to the care of EUPs (“Acute Urological Unit”) or dedicated registrars or operating theatres (“Hybrid structures”). In some services, EUPs bypassed emergency department assessment and were referred directly to urology (“Urological Assessment Unit”) or were managed by other dedicated means. Allocating services to EUPs was associated with reduced time-to-theatre, length of stay and hospital cost, and improved supervision of junior medical staff. Conclusion Multiple dedicated models of care exist for EUPs. Low-level evidence suggests these may improve outcomes for patients, staff and hospitals. Higher quality studies are required to explore patient outcomes and minimum requirements to establish these models.
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Ngo H, Forero R, Mountain D, Fatovich D, Man WN, Sprivulis P, Mohsin M, Toloo S, Celenza A, Fitzgerald G, McCarthy S, Hillman K. Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013. PLoS One 2018; 13:e0193902. [PMID: 29538401 PMCID: PMC5851625 DOI: 10.1371/journal.pone.0193902] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 02/22/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning. METHODS A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique. FINDINGS There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most 'crowded' ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing. CONCLUSIONS The FHR had a consistent effect on 'flow' measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.
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Affiliation(s)
- Hanh Ngo
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
| | - Roberto Forero
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - David Mountain
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Sir Charles Gairdner Hospital, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Daniel Fatovich
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- Royal Perth Hospital, Perth, WA, Australia
- Centre for Clinical Research in Emergency, University of Western Australia, Nedlands, Perth, WA, Australia
| | - Wing Nicola Man
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - Peter Sprivulis
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, SWSLHD, NSW Health, Liverpool, Sydney, NSW, Australia
- School of Psychiatry, Faculty of Medicine, UNSW, Kensington, Sydney, NSW, Australia
| | - Sam Toloo
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Antonio Celenza
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Gerard Fitzgerald
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Sally McCarthy
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- Emergency Care Institute, NSW Agency for Clinical Innovation, Chatswood, Sydney, NSW, Australia
- Prince of Wales Clinical School, UNSW, Randwick, Sydney, NSW Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
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Impact of an acute surgical unit in appendicectomy outcomes: A systematic review and meta-analysis. Int J Surg 2018; 50:114-120. [PMID: 29337180 DOI: 10.1016/j.ijsu.2017.12.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/20/2017] [Accepted: 12/28/2017] [Indexed: 01/06/2023]
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Blay N, Roche MA, Duffield C, Gallagher R. Intrahospital transfers and the impact on nursing workload. J Clin Nurs 2017; 26:4822-4829. [PMID: 28382638 DOI: 10.1111/jocn.13838] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2017] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To determine the rate of patient moves and the impact on nurses' time. BACKGROUND Bed shortages and strategies designed to increase patient flow have led to a global increase in patient transfers between wards. The impact of transferring patients between wards and between beds within a ward on nurses' workload has not previously been measured. DESIGN A two-stage sequential study. Retrospective analysis of hospital data and a prospective observational-timing study. METHODS Secondary analysis of an administrative data set to inform the rate of ward and bed transfers (n = 34,715) was undertaken followed by an observational-timing study of nurses' activities associated with patient transfers (n = 75). RESULTS Over 10,000 patients were moved 34,715 times in 1 year which equates to an average of 2.4 transfers per patient. On average, patient transfers took 42 min and bed transfers took 11 min of nurses' time. Based on the frequency of patient moves, 11.3 full-time equivalent nurses are needed to move patients within the site hospital each month. CONCLUSION Transferring patients is workload intensive on nurses' time and should be included in nursing workload measurement systems. RELEVANCE TO CLINICAL PRACTICE Nurses at the site hospital spend over 1700 hr each month on activities associated with transferring patients, meaning that less time is available for nursing care.
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Affiliation(s)
- Nicole Blay
- Centre for Health Services Management, Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.,Western Sydney University, Parramatta, NSW, Australia
| | - Michael A Roche
- Centre for Health Services Management, Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.,Mental Health Drug and Alcohol Nursing, Northern Sydney Local Health District, North Ryde, NSW, Australia.,School of Nursing, Midwifery & Paramedicine, Australian Catholic University, North Sydney, NSW, Australia
| | - Christine Duffield
- Centre for Health Services Management, Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.,Nursing and Health Services Management, Edith Cowen University, Joondalup, WA, Australia
| | - Robyn Gallagher
- Charles Perkins Centre, Sydney Nursing School, University of Sydney, Camperdown, NSW, Australia
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Banu P, Constantin VD, Popa F, Motofei I, Bălălău C. Cholecystectomy in cirrhotic patients – how safe is it? JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2017. [DOI: 10.25083/2559.5555.21.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Liver cirrhosis is a major health problem worldwide with a prevalence that varies greatly from one geographical area to another. Besides the risk factors common to the general population to develop gallstone disease such as advanced age, female sex or positive family history of gallstones, in patients with liver cirrhosis there are additional risk factors that contribute to the occurrence of gallstones. They are more frequent in patients with a longer duration of the disease and in Child B and C stages. Gallstones disease occurs three times more frequently in patients with liver cirrhosis than in non-cirrhotic patients. Surgery is required if symptoms or complications related to the presence of gallstones occur and a thorough preoperative evaluation and optimization of patient’s condition is necessary prior to surgery. The procedure of choice in these situations is laparoscopic cholecystectomy. The technique has some particularities resulting from local anatomical changes and conversion to open technique remains low and morbidity and mortality rates are within acceptable limits.
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Dickfos M, Ibrahim H, Evans A, Franz R. Cohort study on emergency general surgery patients and an observation unit. ANZ J Surg 2017; 88:713-717. [PMID: 28370979 DOI: 10.1111/ans.13960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/27/2017] [Accepted: 02/08/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Medium-sized, non-trauma hospitals experience many of the same difficulties as tertiary centres do when it comes to managing emergency general surgery patients. However, acute surgical units are not a financially viable option in these hospitals. To improve the care of emergency general surgery patients at one such hospital, a Rapid Assessment Medical Surgical (RAMS) unit was developed to decrease the time to review and increase the efficiency in caring for these patients. METHODS To assess the unit's effect, a prospective analysis was completed of the patients who came through the RAMS unit over a 6-month period and compared with a retrospective analysis of patients presenting in the same 6-month period the year prior to the unit's instigation. RESULTS The RAMS unit was effective in providing an avenue for faster review by the surgical team. This resulted in patients leaving the emergency department faster, decreased the number of patients that breached emergency department time-targets and increased the number of patients discharged after a period of observation or basic treatments. CONCLUSION General surgery patients were managed more efficiently with the RAMS unit in place. However, a full cost analysis is required to determine if such units are cost-effective.
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Affiliation(s)
- Marilla Dickfos
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Hany Ibrahim
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Andrew Evans
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Robert Franz
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
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