1
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Quaile O, Perrodin SF, Trippel A, Schnüriger B. Characteristics of emergency general surgery services in Switzerland: a nationwide survey. Eur J Trauma Emerg Surg 2024; 50:259-268. [PMID: 37470790 PMCID: PMC10923733 DOI: 10.1007/s00068-023-02272-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/14/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Running an emergency general surgery (EGS) service is challenging and requires significant personnel and institutional resources. The aim of this study was to achieve a nationwide overview of the individual EGS service organizations in public hospitals in Switzerland. METHODS All Swiss public hospitals with a surgical and emergency department were included and contacted by telephone. General surgeons were interviewed between December 2021 and January 2022 using a standardized questionnaire. RESULTS Seventy-two out of 79 public hospitals in Switzerland (91.1%) agreed to the survey. They employed 1,581 surgeons in 19 (26.4%) hospitals with < 100 beds, 39 (54.2%) hospitals with 100-300 beds, 7 (9.7%) with 300-600 beds, and 7 (9.7%) with > 600 beds. The median number of surgeons per hospital was 20.5 (IQR 13.0-29.0). Higher level of care (intermediate or intensive care unit) was significantly less available in small hospitals (< 100 beds). The median hour of designated emergency operating room capacity per day was 14 h (IQR 14-24) for all hospitals with < 600 beds and 24 h (IQR 14-24) for the largest hospitals (> 600 beds). With increasing hospital size, there was a significant increase in the number of surgical units where EGS and orthopedic trauma surgery were covered by two separate teams (21.1% vs. 43.6% vs. 85.7% vs. 100%, p = 0.035). The median number of surgeons on-call per hospital and per 24 h was 5.0 (IQR 3.3-6.0). CONCLUSION Lack of higher level of care in small hospitals, limited emergency OR capacity and short rotations of on-call teams are major drawbacks of many current EGS systems in Switzerland. Centralization of critically ill EGS patients and reorganization of surgical on-call systems to designated acute care surgery teams should be considered.
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Affiliation(s)
- Oliver Quaile
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stéphanie Fabienne Perrodin
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Amedeo Trippel
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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2
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Panwar Y, Shan S, Owens L, Kang C, Hodgson R. Inefficient Admissions for Abdominal Pain Under an Acute General Surgical Unit. World J Surg 2023; 47:2401-2408. [PMID: 37351592 PMCID: PMC10474195 DOI: 10.1007/s00268-023-07096-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND The acute general surgical unit (AGSU) model has become a standard of efficient acute surgical care. Whilst the AGSU has been compared to the traditional surgical model, there is a lack of research auditing referrals and admissions. This study evaluates abdominal pain referrals to AGSU and the necessity of admission. METHODS A retrospective cohort study of adult abdominal pain admissions was conducted over a two-year period at a single centre in metropolitan Victoria, Australia. The data were extracted from electronic medical records and key endpoints of data included the diagnosis, length of stay, investigations and subjective pain outcomes. RESULTS A total of 1587 patients met the study criteria of which 1116 (70.3%) had a non-surgical diagnosis with the majority having non-specific abdominal pain. The non-surgical patients had a lower median length of stay (25.3 h) compared to surgical patients (44.2 h, p < 0.001). They were less likely to have an abnormal haemoglobin (p = 0.004), elevated white cell count (p = 0.02) or elevated C-reactive protein > 50 mg/L (p < 0.001). On multivariable analysis, surgical patients had higher odds of having a CRP > 50 mg/L (p = 0.024) and a positive imaging result (p < 0.001). The patient's pain control also correlated with length of stay. CONCLUSION A large population of patients with non-specific abdominal pain are admitted to AGSU. These patients do not require surgery and have a short length of stay. Incorporating a negative CRP result and negative imaging result may be utilised in conjunction with optimised analgesia to help avoid these unnecessary admissions, thereby improving AGSU efficiency and workload.
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Affiliation(s)
- Yash Panwar
- Division of Surgery, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | - Sam Shan
- Division of Surgery, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | - Lily Owens
- Division of Surgery, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | - Chiu Kang
- Division of Surgery, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
- Department of Surgery, University of Melbourne, Epping, Australia
| | - Russell Hodgson
- Division of Surgery, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia.
- Department of Surgery, University of Melbourne, Epping, Australia.
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3
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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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4
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Young E, Khoo TW, Trochsler MI, Maddern GJ. Factors influencing interhospital transfer delays in emergency general surgery: a systematic review and narrative synthesis. ANZ J Surg 2022; 92:1314-1321. [PMID: 35437859 DOI: 10.1111/ans.17718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/09/2022] [Accepted: 04/02/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Emergency general surgery is an emerging public health issue globally, with substantial healthcare burden. Interhospital transfer of critically unwell surgical patients has been the mainstay of bridging gaps in surgical coverage in regional and rural locations, despite evidence of greater morbidity and mortality. Delays in transfer invariably occurs and compounds the situation. Our aim was to examine the factors influencing interhospital transfer delays in emergency general surgical patients. METHODS A systematic search of PubMED and EmBase, was performed by two researchers from 2020 to 23rd Feb 2021, for English articles related to interhospital transfer delays in emergency general surgical patients, with an age of >16. Articles were critically appraised and data were extracted into a pre-specified data extraction form. No data was suitable for statistical analysis and a narrative synthesis was performed instead. RESULTS Six relevant articles were identified from the search. All studies were retrospective cohort studies with moderate to high risk of bias. Lack of consultant surgeon input, after hours transfer, need for intensive care bed and poor transfer documentation may have a role in interhospital transfer delays. Patients with public health insurance, multiple comorbidities and non-emergency medical conditions experience longer transfer request time and may be at risk of precipitating interhospital transfer delays. Transfer delays are seen in transfers over longer distances. CONCLUSION There is a paucity of knowledge on what and how factors influence interhospital transfer delays in emergency general surgical patients. Well-designed prospective cohort studies are required to bridge this knowledge gap.
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Affiliation(s)
- Edward Young
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Teng-Wei Khoo
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Markus Ivo Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Guy John Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
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5
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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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6
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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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7
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Gounder J, Dissanayake B, Burstow MJ, Yuide PJ, Naidu S, Lancashire RP, Chua TC. Comparative analysis of emergency general surgery on-call structure and its impact on emergency appendicectomy outcomes. ANZ J Surg 2021; 91:616-621. [PMID: 33459510 DOI: 10.1111/ans.16558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/21/2020] [Accepted: 12/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND In Australia, there has been a shift from the traditional 'on-call' surgical model to the 'acute surgical unit' (ASU) model to improve outcomes in acute general surgery. Using emergency appendicectomy as a standardized procedure, we aimed to identify the different patterns of care between these on-call structures by comparing two metropolitan district hospitals; one that employs a traditional on-call model and the other, which employ the ASU model. METHODS Data on consecutive patients undergoing emergency appendectomies at the two hospitals (traditional and ASU model) between July 2018 and December 2018 were retrieved for retrospective review. Patient factors, preoperative factors, operative factors and post-operative outcomes were collected and tabulated for comparative analysis between the traditional versus ASU model of care. RESULTS Univariate analysis demonstrated that there were a greater proportion of consultant-led cases (P < 0.001), a shorter time to theatre (P = 0.047) and a greater number of out-of-hours operations (P < 0.001) in the ASU model compared to the traditional model. A larger proportion of patients from the traditional model underwent a computed tomography scan as part of their diagnostic workup compared to the ASU model (P < 0.001). There was no difference in negative appendicectomy rates, intraoperative conversion rates, post-operative complication rates or mean lengths of hospital stay between the two on-call models. CONCLUSION The ASU and traditional on-call model appears to achieve equivalent care outcomes for patients with acute appendicitis.
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Affiliation(s)
- Jaya Gounder
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Bhanuka Dissanayake
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Department of Surgery, Logan Hospital, Logan City, Queensland, Australia
| | - Matthew J Burstow
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Department of Surgery, Logan Hospital, Logan City, Queensland, Australia
| | - Peter J Yuide
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Department of Surgery, Logan Hospital, Logan City, Queensland, Australia
| | - Sanjeev Naidu
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Queensland, Australia
| | | | - Terence C Chua
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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8
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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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9
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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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10
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Kaya C, Yang PF, Wong SW, Truskett PG. Outcomes of an acute care surgery model: a 10-year follow-up study. ANZ J Surg 2020; 90:257-261. [PMID: 31943601 DOI: 10.1111/ans.15655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 10/09/2019] [Accepted: 11/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Many hospitals across Australia and New Zealand have implemented acute care surgery (ACS) models over the past decade, often with improved outcomes such as reductions in wait time to surgery, complications and length of stay. The aim of this study was to evaluate the outcomes of patients who underwent non-elective appendicectomy and cholecystectomy and compare these with the results observed shortly after the implementation of an ACS model at our institution 10 years earlier. METHODS A retrospective review of contemporary patients who underwent non-elective appendicectomy and cholecystectomy compared with historical data was performed. Primary outcomes were wait time to surgery, surgical complications and length of stay. RESULTS In the contemporary cohort, 263 patients underwent non-elective appendicectomy over a 1-year period compared with 226 patients in the historical cohort. The median wait time to surgery had increased (17.7 versus 9.6 h, P < 0.001). There was no significant difference in a composite end-point of complications and readmissions (8.0% versus 9.3%, P = 0.61). The length of stay was unchanged. There was greater use of preoperative imaging and reduced overnight operating. For non-elective cholecystectomies, 132 patients underwent this procedure in the contemporary cohort over a 2-year period compared with 115 patients in the historical cohort. There were no significant differences in wait time to surgery (2 versus 1 day, P = 0.13) or complications (9.8% versus 8.7%, P = 0.75). The length of stay was unchanged. CONCLUSION The majority of improvements seen shortly following the implementation of an ACS model have been sustained after 10 years.
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Affiliation(s)
- Cigdem Kaya
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Phillip F Yang
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Shing W Wong
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Philip G Truskett
- Department of Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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11
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Kinnear N, Tran M, Han J, Jolly S, Herath M, Hennessey D, Dobbins C, Sammour T, Moore J. Does emergency general surgery model affect staff satisfaction, training and working hours? ANZ J Surg 2019; 90:262-267. [DOI: 10.1111/ans.15628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/15/2019] [Accepted: 11/16/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Ned Kinnear
- Discipline of Surgery, Faculty of Medical and Health Sciences, Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Minh Tran
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Jennie Han
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Samantha Jolly
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Matheesha Herath
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | | | - Christopher Dobbins
- Discipline of Surgery, Faculty of Medical and Health Sciences, Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
| | - Tarik Sammour
- Discipline of Surgery, Faculty of Medical and Health Sciences, Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - James Moore
- Discipline of Surgery, Faculty of Medical and Health Sciences, Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
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12
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Kinnear N, Heijkoop B, Bramwell E, Frazzetto A, Noll A, Patel P, Hennessey D, Otto G, Dobbins C, Sammour T, Moore J. Communication and management of incidental pathology in 1,214 consecutive appendicectomies; a cohort study. Int J Surg 2019; 72:185-191. [PMID: 31683040 DOI: 10.1016/j.ijsu.2019.10.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/08/2019] [Accepted: 10/23/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Important incidental pathology requiring further action is commonly found during appendicectomy, macro- and microscopically. We aimed to determine whether the acute surgical unit (ASU) model improved the management and disclosure of these findings. METHODS An ASU model was introduced at our institution on 01/08/2012. In this retrospective cohort study, all patients undergoing appendicectomy 2.5 years before (Traditional group) or after (ASU group) this date were compared. The primary outcomes were rates of appropriate management of the incidental findings, and communication of the findings to the patient and to their general practitioner (GP). RESULTS 1,214 patients underwent emergency appendicectomy; 465 in the Traditional group and 749 in the ASU group. 80 (6.6%) patients (25 and 55 in each respective period) had important incidental findings. There were 24 patients with benign polyps, 15 with neuro-endocrine tumour, 11 with endometriosis, 8 with pelvic inflammatory disease, 8 Enterobius vermicularis infection, 7 with low grade mucinous cystadenoma, 3 with inflammatory bowel disease, 2 with diverticulitis, 2 with tubo-ovarian mass, 1 with secondary appendiceal malignancy and none with primary appendiceal adenocarcinoma. One patient had dual pathologies. There was no difference between the Traditional and ASU group with regards to communication of the findings to the patient (p = 0.44) and their GP (p = 0.27), and there was no difference in the rates of appropriate management (p = 0.21). CONCLUSION The introduction of an ASU model did not change rates of surgeon-to-patient and surgeon-to-GP communication nor affect rates of appropriate management of important incidental pathology during appendectomy.
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Affiliation(s)
- Ned Kinnear
- Dept of Surgery, Lyell McEwin Hospital, Adelaide, Australia; Dept of Surgery, Port Augusta Hospital, Port Augusta, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia.
| | | | - Eliza Bramwell
- Dept of Surgery, Port Augusta Hospital, Port Augusta, Australia
| | - Alannah Frazzetto
- Dept of Surgery, Port Augusta Hospital, Port Augusta, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Amy Noll
- Dept of Surgery, Port Augusta Hospital, Port Augusta, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Prajay Patel
- Dept of Surgery, Port Augusta Hospital, Port Augusta, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | | | - Greg Otto
- Dept of Surgery, Lyell McEwin Hospital, Adelaide, Australia
| | | | - Tarik Sammour
- Dept of Surgery, Royal Adelaide, Hospital, Adelaide, Australia; Dept of Surgery, Faculty of Medical and Health Sciences, University of Adelaide, Adelaide, Australia
| | - James Moore
- Dept of Surgery, Royal Adelaide, Hospital, Adelaide, Australia; Dept of Surgery, Faculty of Medical and Health Sciences, University of Adelaide, Adelaide, Australia
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13
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Barnett DR, Lu H, Finlay B, Coventry C, Granchi N, Marshall-Webb M, Heitmann P, Dobbins C. Lessons learned from relocating an acute surgical unit to a new quaternary referral centre in Adelaide, South Australia: a tale of two hospitals. ANZ J Surg 2019; 89:1620-1625. [PMID: 31637831 DOI: 10.1111/ans.15498] [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: 07/31/2019] [Revised: 08/28/2019] [Accepted: 08/31/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND On 4 September 2017, patient care was relocated from one quaternary hospital that was closing, to another proximate greenfield site in Adelaide, Australia, this becoming the new Royal Adelaide Hospital. There are currently no data to inform how best to transition hospitals. We conducted a 12-week prospective study of admissions under our acute surgical unit to determine the impact on our key performance indicators. We detail our results and describe compensatory measures deployed around the move. METHODS Using a standard proforma, data were collected on key performance indicators for acute surgical unit patients referred by the emergency department (ED). This was supplemented by data obtained from operative management software and coding data from medical records to build a database for analysis. RESULTS Five hundred and eight patients were admitted during the study period. Significant delays were seen in times to surgical referral, surgical review and leaving the ED. Closely comparable was time spent in the surgical suite. Uptake of the Ambulatory Care Pathway fell by 67% and the Rapid Access Clinic by 46%. Overall mortality and patient length of stay were not affected. CONCLUSION We found the interface with ED was most affected. Staff encountered difficulties familiarizing with a new environment and an anecdotally high number of ED presentations. Delays to referral and surgical review resulted in extended patient stay in ED. Once in theatre, care was comparable pre- and post-transition. This was likely from early identification of patients requiring an emergency operation, close consultant surgeon involvement and robust working relationships between surgeons, anaesthetists and nurses.
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Affiliation(s)
- Dylan R Barnett
- Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ha Lu
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ben Finlay
- Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Charlie Coventry
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nelson Granchi
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Matthew Marshall-Webb
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Paul Heitmann
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher Dobbins
- Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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14
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An Acute General Surgical Unit (AGSU) Negates the Impact of the Tokyo Guidelines 2018 (TG18) Diagnostic Criteria for the Treatment of Acute Cholecystitis. World J Surg 2019; 43:2762-2769. [PMID: 31384994 DOI: 10.1007/s00268-019-05104-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE The Tokyo Guidelines 2018 (TG18) were developed to aid diagnosis and treatment for acute cholecystitis. The benefits of being treated in an acute general surgical unit (AGSU) include earlier diagnosis and treatment. This study aims to define the usefulness of TG18 before and after the introduction of AGSU. METHODOLOGY Patients who underwent cholecystectomy at Northern Health were audited retrospectively and assessed for TG18 diagnostic criteria and outcomes between 1 February 2012 and 1 February 2014 (one-year pre- and post-AGSU). RESULTS Five hundred and eighty-seven patients underwent emergency cholecystectomy with 203 (34.6%) patients having a suspected diagnosis, and 234 (39.9%) patients with a definitive diagnosis of acute cholecystitis using TG18 diagnostic criteria. After the introduction of AGSU, time from imaging to operation improved from 2.5 to 1.7 days (p = 0.012). There were more operations occurring during in-hours following AGSU implementation (75.8% vs. 62.7%, p < 0.001). Maximum pre-operative CRP of >26.6 mg/L had a higher likelihood of Clavien-Dindo complication grade 3 or 4 (OR 3.86, 95%CI 1.18-12.63, p = 0.027) compared with TG18 definitive diagnosis criteria (OR 1.50, 95%CI 0.46-4.91, p = 0.501). Surprisingly, there was a trend towards higher complications and readmissions for patients operated within 24 h, although this trend was not significant. CONCLUSION Patients with suspected acute cholecystitis should be stratified clinically and with CRP in an AGSU with TG18 adding little value in a busy metropolitan unit.
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15
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Ang ZH, Wong S, Truskett P. General Surgeons Australia's 12-point plan for emergency general surgery. ANZ J Surg 2019; 89:809-814. [PMID: 31280492 DOI: 10.1111/ans.15327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/13/2022]
Abstract
In the last decade, emergency general surgery (EGS) in Australia and New Zealand has seen a transition from the traditional on-call system to the acute surgical unit (ASU) model. The importance and growing demand for EGS has resulted in the implementation of the General Surgeons Australia's 12-point plan for emergency surgery. Since its release, the 12-point plan has been used as a benchmark of a well-functioning ASU, both locally and abroad. This study aims to provide a descriptive review on the relevance of the 12-point plan to the ASU model and review the current evidence to support this framework. The review concludes that the establishment of the ASU model has met the aims set out by the Royal Australasian College of Surgeons for EGS. The 12-point plan is relevant and has good evidence to support its framework.
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Affiliation(s)
- Zhen Hao Ang
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shing Wong
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Philip Truskett
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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16
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Fehlberg T, Rose J, Guest GD, Watters D. The surgical burden of disease and perioperative mortality in patients admitted to hospitals in Victoria, Australia: a population-level observational study. BMJ Open 2019; 9:e028671. [PMID: 31118179 PMCID: PMC6549668 DOI: 10.1136/bmjopen-2018-028671] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/14/2019] [Accepted: 04/24/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Comprehensive reporting of surgical disease burden and outcomes are vital components of resilient health systems but remain under-reported. The primary objective was to identify the Victorian surgical burden of disease necessitating treatment in a hospital or day centre, including a thorough epidemiology of surgical procedures and their respective perioperative mortality rates (POMR). DESIGN Retrospective population-level observational study. SETTING The study was conducted in Victoria, Australia. Access to data from the Victorian Admitted Episodes Dataset was obtained using the Dr Foster Quality Investigator tool. The study included public and private facilities, including day-case facilities. PARTICIPANTS From January 2014 to December 2016, all admissions with an International Statistical Classification of Diseases-10 code matched to the Global Health Estimates (GHE) disease categories were included. PRIMARY AND SECONDARY OUTCOME MEASURES Admissions were assigned a primary disease category according to the 23 GHE disease categories. Surgical procedures during hospitalisations were identified using the Australian Refined Diagnosis Related Groups (AR-DRG). POMR were calculated for GHE disease categories and AR-DRG procedures. RESULTS A total of 4 865 226 admitted episodes were identified over the 3-year period. 1 715 862 (35.3%) of these required a surgical procedure. The mortality rate for those undergoing a procedure was 0.42%, and 1.47% for those without. The top five procedures performed per GHE category were lens procedures (162 835 cases, POMR 0.001%), caesarean delivery (76 032 cases, POMR 0.01%), abortion with operating room procedure (65 451 cases, POMR 0%), hernia procedures (52 499 cases, POMR 0.05%) and other knee procedures (47 181 cases, POMR 0.004%). CONCLUSIONS Conditions requiring surgery were responsible for 35.3% of the hospital admitted disease burden in Victoria, a rate higher than previously published from Sweden, New Zealand and the USA. POMR is comparable to other studies reporting individual procedures and conditions, but has been reported comprehensively across all GHE disease categories for the first time.
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Affiliation(s)
- Trafford Fehlberg
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - John Rose
- Department of Plastics and Reconstructive Surgery, Johns Hopkins, Baltimore, Maryland, USA
| | - Glenn Douglas Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - David Watters
- Royal Australasian College of Surgeons, Geelong, Victoria, Australia
- Surgery, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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17
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Teo A, Wang C, Wilson RB. Time is of the essence: evaluation of emergency department triage and time performance in the preoperative management of acute abdomen. ANZ J Surg 2019; 89:1102-1107. [PMID: 31115159 DOI: 10.1111/ans.15255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 03/12/2019] [Accepted: 03/31/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute abdomen is a time-critical condition, which requires prompt diagnosis, initiation of first-line preoperative therapy and expedient surgical intervention. The earliest opportunity to intervene occurs at presentation to the emergency department triage. The aim of this audit was to evaluate the relationship between emergency triage and time performance measures in the preoperative management of abdominal emergencies. METHODS Retrospective audit of time performance measures of key clinical events from emergency triage. Patient characteristics, elapsed time from triage to commencement of fluid resuscitation, intravenous antibiotics and emergency surgery and post-operative outcomes were obtained from review of operative medical records data over a 1-year duration. RESULTS There was variability in triage allocation of patients with acute abdomen requiring urgent surgery. Category 3 was the most commonly assigned triage category (65.6%). The majority of patients (94.8%) had initial clinical assessment within the National Emergency Access Target '4-hour' rule, and 41.7% seen within 1-h from triage. Despite this, in cases of intra-abdominal sepsis, there was nearly a fourfold elapsed time for first dose intravenous antibiotics, beyond the 1-h recommendation in the Sepsis Kills pathway. There was non-significant trend in faster overall time performances with successive higher triage category allocation. CONCLUSION This study highlights an opportunity to consider alternative triage methods or fast-track of patients with acute abdomen to promote early surgical assessment, resuscitation, antibiotic therapy and definitive intervention.
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Affiliation(s)
- Adrian Teo
- Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,The University of New South Wales, Sydney, New South Wales, Australia
| | - Cindy Wang
- Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Robert B Wilson
- Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,The University of New South Wales, Sydney, New South Wales, Australia
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18
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Coventry CA, Holland AJA, Read DJ, Ivers RQ. Australasian general surgical training and emergency medical teams: a review. ANZ J Surg 2019; 89:815-820. [PMID: 31066168 DOI: 10.1111/ans.15158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/24/2019] [Accepted: 02/26/2019] [Indexed: 01/09/2023]
Abstract
Emergency medical teams (EMTs) have provided surgical care in sudden-onset disasters in low- and middle-income countries. General surgeons have been heavily involved in many EMTs due to their traditional broad set of surgical skills and experience. With the increased subspecialization of general surgical training in many high-income countries, including Australia and New Zealand, finding general surgeons with adequately broad experience is becoming more challenging. Furthermore, it is now considered standard for EMTs deploying to a sudden-onset disaster to have undergone credentialing, demonstrating sufficient training of their deployed members. The purpose of this review was to highlight the challenges and potential solutions facing those involved in training and recruiting general surgeons for EMTs in Australasia.
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Affiliation(s)
- Charles A Coventry
- Children's Hospital at Westmead Clinic School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew J A Holland
- Children's Hospital at Westmead Clinic School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - David J Read
- National Critical Care and Trauma Response Centre, Darwin, Northern Territory, Australia
| | - Rebecca Q Ivers
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, New South Wales, Australia
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19
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Kinnear N, Bramwell E, Frazzetto A, Noll A, Patel P, Hennessey D, Otto G, Dobbins C, Sammour T, Moore J. Acute surgical unit improves outcomes in appendicectomy. ANZ J Surg 2019; 89:1108-1113. [PMID: 30989789 DOI: 10.1111/ans.15141] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/28/2019] [Accepted: 02/11/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Ned Kinnear
- Department of SurgeryLyell McEwin Hospital Adelaide South Australia Australia
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
| | - Eliza Bramwell
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
| | - Alannah Frazzetto
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
| | - Amy Noll
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
| | - Prajay Patel
- Department of SurgeryPort Augusta Hospital Port Augusta South Australia Australia
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
| | | | - Greg Otto
- Department of SurgeryLyell McEwin Hospital Adelaide South Australia Australia
| | - Christopher Dobbins
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - Tarik Sammour
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
| | - James Moore
- Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of SurgeryRoyal Adelaide Hospital Adelaide South Australia Australia
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20
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Symons NRA, McArthur D, Miller A, Verjee A, Senapati A. Emergency general surgeons, subspeciality surgeons and the future management of emergency surgery: results of a national survey. Colorectal Dis 2019; 21:342-348. [PMID: 30444316 DOI: 10.1111/codi.14474] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/30/2018] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to survey consultants' experience of working as or with emergency general surgery (EGS) surgeons and to investigate the role they fulfil in the management of general and subspeciality emergencies. METHOD An electronic survey, designed to capture both quantitative and qualitative data, was piloted and then circulated to members of the Association of Coloproctology of Great Britain and Ireland. RESULTS Two hundred and forty-two responses were received from 848 recipients (a 29% response rate) covering 104 of 135 (77%) acute NHS Trusts in England. EGS surgeons were in post in 43/141 (30%) hospitals overall and 12/24 (50%) of hospitals in London. Most respondents working in units with EGS surgeons found them to be advantageous (46/63, 73%). Consultants working with EGS surgeons were significantly more likely to support their use (49/63, 78%) than those without them (83/178, 47%) (χ2 = 16.9, P < 0.001). EGS surgeons were considered to improve the delivery of EGS (78%), create time for subspecialists (70%) and provide service (73%). However, there were concerns about the quality of surgery (43%), an insufficient standard of specialist care (54%) and compromise in the training of juniors (25%). Respondents commented on a lack of job structure with a high attrition rate (21%), the insufficient quality of applicants (18%) and that subspecialization and split on-call was preferable (17%). CONCLUSION Respondents were supportive of the ability of EGS surgeons to relieve pressure on subspecialists; however, there were significant concerns about the sustainability and quality of the EGS surgeon role. Emergency colorectal resections should have the input of a surgeon who performs elective colorectal resections.
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Affiliation(s)
- N R A Symons
- Imperial College London and Speciality Registrar in General Surgery, North East Thames, London, UK
| | - D McArthur
- Heart of England Foundation Trust, Birmingham, UK
| | - A Miller
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - A Verjee
- ACPGBI Patient Liaison Group, London, UK
| | - A Senapati
- ACPGBI EGS Working Group and Portsmouth Hospitals NHS Trust, Portsmouth, UK
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21
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Bazzi ZT, Kinnear N, Bazzi CS, Hennessey D, Henneberg M, Otto G. Impact of an acute surgical unit on outcomes in acute cholecystitis. ANZ J Surg 2018; 88:E835-E839. [DOI: 10.1111/ans.14802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Zacharia T. Bazzi
- Department of Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
| | - Ned Kinnear
- Department of Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
- Department of Urology; Austin Health; Melbourne Victoria Australia
| | - Ciara S. Bazzi
- Department of Surgery; Modbury Hospital; Adelaide South Australia Australia
| | - Derek Hennessey
- Department of Urology; Austin Health; Melbourne Victoria Australia
| | - Maciej Henneberg
- Department of Medical Sciences; The University of Adelaide; Adelaide South Australia Australia
| | - Greg Otto
- Department of Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
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22
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van Zyl TJ, Murphy PB, Allen L, Parry NG, Leslie K, Vogt KN. Beyond just the operating room: characterizing the complete caseload of a tertiary acute care surgery service. Can J Surg 2018; 61:7417. [PMID: 29806803 DOI: 10.1503/cjs.007417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Most studies evaluating acute care surgery (ACS) models of care for patients with emergency general surgery (EGS) conditions have focused on patients who undergo surgery while admitted under the care of the ACS service. The purpose of this study was to prospectively examine the case-mix of admissions and consultations to an ACS service at a tertiary centre to identify the frequency and distribution of both operatively and nonoperatively managed EGS conditions. METHODS In this prospective cohort study, we evaluated consecutive patients assessed by the ACS team between July 1 and Aug. 31, 2015, at a large Canadian tertiary care centre. This included all consultations and outside hospital transfers. Diagnoses, demographic characteristics, comorbidities, intervention(s), complications, readmission and in-hospital death were captured. RESULTS The ACS team was involved in the care of 359 patients, 176 (49.0%) of whom were admitted under the direct care of the ACS team. Nonoperative care was indicated in 82 patients (46.6%) admitted to the ACS service and 151 (82.5%) of those admitted to a non-ACS service (p < 0.001). Bowel obstruction (37 patients [21.0%]) was the most common reason for admission, followed by wound/abscess (24 [13.6%), biliary disease (24 [13.6%]) and appendiceal disease (23 [13.1%]). Rates of 30-day return to the emergency department and readmission were 17.0% and 9.1%, respectively, and the in-hospital mortality rate was 1.7%. CONCLUSION Acute care surgery teams care for a wide breadth of disease, a considerable amount of which is managed nonoperatively.
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Affiliation(s)
- Theunis J van Zyl
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Patrick B Murphy
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Laura Allen
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Neil G Parry
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Ken Leslie
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
| | - Kelly N Vogt
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (van Zyl); the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Allen, Parry, Leslie, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Parry, Vogt); and the Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Parry)
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23
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Emergency laparotomy outcomes before and after the introduction of an acute surgical unit. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2017.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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24
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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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Kiermeier A, Babidge WJ, McCulloch GAJ, Maddern GJ, Watters DA, Aitken RJ. National surgical mortality audit may be associated with reduced mortality after emergency admission. ANZ J Surg 2017; 87:830-836. [DOI: 10.1111/ans.14170] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 06/27/2017] [Accepted: 06/28/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Andreas Kiermeier
- Statistical Process Improvement Consulting and Training Pty Ltd.; Adelaide South Australia Australia
| | - Wendy J. Babidge
- Audit and Academic Surgery Division, Royal Australasian College of Surgeons; Adelaide South Australia Australia
| | - Glenn A. J. McCulloch
- South Australian Audit of Perioperative Mortality, Royal Australasian College of Surgeons; Adelaide South Australia Australia
| | - Guy J. Maddern
- Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons; Adelaide South Australia Australia
| | - David A. Watters
- Royal Australasian College of Surgeons; Melbourne Victoria Australia
| | - R. James Aitken
- Western Australian Audit of Surgical Mortality, Royal Australasian College of Surgeons; Perth Western Australia Australia
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Kinnear N, Britten-Jones P, Hennessey D, Lin D, Lituri D, Prasannan S, Otto G. Impact of an acute surgical unit on patient outcomes in South Australia. ANZ J Surg 2017; 87:825-829. [PMID: 28681948 DOI: 10.1111/ans.14100] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/06/2017] [Accepted: 05/09/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Compared with traditional (Trad) systems of managing emergency surgical presentations, the acute surgical unit (ASU) model provides an on-site registrar, on-call surgeon and dedicated emergency theatre, 24 h/day. To date, there have been no Australasian ASU studies of >3000 patients, nor from South Australia. METHODS A retrospective historical control study compared the outcomes of adults admitted to the Lyell McEwin Hospital in the Trad (1 February 2010 to 31 July 2012) and ASU periods (1 August 2012 to 31 January 2015), who underwent an emergency general surgical procedure. RESULTS A total of 4074 patients met inclusion criteria; 1688 and 2386 patients during the Trad and ASU periods, respectively. The cohorts were not significantly different in median age, gender or American Society of Anesthesiologists scores. Compared with the Trad period, improved median time from emergency department referral to theatre start (19.4 h versus 17.9 h, P < 0.0001) and median length of stay (2.32 days versus 2.06 days, P < 0.0001) were observed during the ASU period. The proportion of procedures performed in-hours was similar (77.9% versus 79.6%, P = 0.18). Secondary outcomes of rates of intensive care unit admission, emergency department representation within 30 days, in-hospital mortality and 1-year all-cause mortality were unchanged. CONCLUSION Institution of an ASU was associated with decreased time from referral to theatre and reduced length of stay. The proportion of cases performed in-hours did not change. This may be related to the high Trad period rate and increased workload. These findings represent the largest Australasian study of an ASU and support the current model of care.
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Affiliation(s)
- Ned Kinnear
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia.,Department of Urology, Austin Health, Melbourne, Victoria, Australia
| | - Philip Britten-Jones
- Department of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Derek Hennessey
- Department of Urology, Austin Health, Melbourne, Victoria, Australia
| | - Diwei Lin
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Darren Lituri
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Subhita Prasannan
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Greg Otto
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
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Lardner DR, Brauer CA, Harrop AR, MacRobie A. After hours surgery and mortality: the potential role of acute care surgery models as a factor accounting for results. CMAJ 2017; 189:E219. [PMID: 28246269 DOI: 10.1503/cmaj.732681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- David R Lardner
- Pediatric anesthesiologist, Alberta Children's Hospital, University of Calgary, Calgary, Alta
| | | | - A Rob Harrop
- Plastic surgeon, Alberta Children's Hospital, University of Calgary, Calgary, Alta
| | - Ali MacRobie
- Research assistant, EQuIS, Alberta Children's Hospital, University of Calgary, Calgary, Alta
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Shilton H, Tanveer A, Poh BR, Croagh D, Jayasuriya N, Chan D. Is the acute surgical unit model feasible for Australian regional centres? ANZ J Surg 2016; 86:889-893. [DOI: 10.1111/ans.13724] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 06/28/2016] [Accepted: 07/04/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Hamish Shilton
- Department of General Surgery; Monash Medical Centre, Monash Health; Melbourne Victoria Australia
- Department of Surgery; Monash University; Melbourne Victoria Australia
| | - Amin Tanveer
- Department of General Surgery; Latrobe Regional Hospital; Traralgon Victoria Australia
| | - Benjamin Ruimin Poh
- Department of General Surgery; Monash Medical Centre, Monash Health; Melbourne Victoria Australia
- Department of Surgery; Monash University; Melbourne Victoria Australia
| | - Daniel Croagh
- Department of General Surgery; Monash Medical Centre, Monash Health; Melbourne Victoria Australia
- Department of Surgery; Monash University; Melbourne Victoria Australia
| | - Neil Jayasuriya
- Department of General Surgery; Latrobe Regional Hospital; Traralgon Victoria Australia
| | - David Chan
- Department of General Surgery; Latrobe Regional Hospital; Traralgon Victoria Australia
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30
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Pritchard N, Newbold R, Robinson K, Ooi WM. Effect of the acute general surgical unit: a regional perspective. ANZ J Surg 2015; 87:595-599. [DOI: 10.1111/ans.13403] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2015] [Indexed: 12/01/2022]
Affiliation(s)
| | - Ryan Newbold
- Surgical Unit; St Vincent's Hospital; Fitzroy Victoria Australia
| | | | - Wei Ming Ooi
- General Surgery Unit; Austin Health; Heidelberg Victoria Australia
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Suhardja TS, Bae L, Seah EZ, Cashin P, Croagh DG. Acute surgical unit safely reduces unnecessary after-hours cholecystectomy. Ann R Coll Surg Engl 2015; 97:568-73. [PMID: 26492901 PMCID: PMC5096602 DOI: 10.1308/rcsann.2015.0035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2015] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The acute surgical model has been trialled in several institutions with mixed results. The aim of this study was to determine whether the acute surgical model provides better outcomes for patients with acute biliary presentation, compared with the traditional emergency surgery model of care. METHODS A retrospective review was carried out of patients who were admitted for management of acute biliary presentation, before and after the establishment of an acute surgical unit (ASU). Outcomes measured were time to operation, operating time, after-hours operation (6pm - 8am), length of stay and surgical complications. RESULTS A total of 342 patients presented with acute biliary symptoms and were managed operatively. The median time to operation was significantly reduced in the ASU group (32.4 vs 25.4 hours, p=0.047), as were the proportion of operations performed after hours (19.5% vs 2.5%, p<0.001) and the median length of stay (4 vs 3 days, p<0.001). The median operating time, rate of conversion to open cholecystectomy and wound infection rates remained similar. CONCLUSIONS Implementation of an ASU can lead to objective differences in outcomes for patients who present with acute cholecystitis. In our study, the ASU significantly reduced time to operation, the number of operations performed after hours and length of stay.
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Affiliation(s)
| | - L Bae
- Monash Health, Clayton, VIC , Australia
| | - E Z Seah
- Monash Health, Clayton, VIC , Australia
| | - P Cashin
- Monash Health, Clayton, VIC , Australia
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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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Cao AM, Eslick GD, Cox MR. Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case–control studies. Surg Endosc 2015; 30:1172-82. [DOI: 10.1007/s00464-015-4325-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 06/08/2015] [Indexed: 12/13/2022]
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Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies. Surg Endosc 2015; 30:1183. [PMID: 26139487 DOI: 10.1007/s00464-015-4471-8] [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: 12/13/2022]
Abstract
BACKGROUND Since the advent of laparoscopic cholecystectomy (LC) there has been continued debate regarding the management of acute cholecystitis with either early or delayed LC. Nearly all studies have demonstrated that early LC has a significantly shorter total length of hospital stay compared with delayed LC. Although previous randomized controlled trials and meta-analysis have shown clinical outcomes to favour early surgery, clinical practice continues to vary significantly worldwide. In addition, there is much confusion in the optimal timing for early LC with definitions of early varying from 72 h to 7 days. There have been numerous case-control studies investigating the timing of LC in acute cholecystitis. The aim of this paper is to pool the results from all case-control studies to investigate outcomes including mortality rates, complication rates, length of hospital stay and conversion rates to open procedures. METHODS A search of electronic databases was performed for case-control studies published between 1985-February 2015. RESULTS Results from 77 case-control studies showed statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC. Although LC within the 72-h window is optimal, patients operated after this window still benefit from early surgery compared to delayed surgery. The duration of symptoms in acute cholecystitis should not influence the surgeons' willingness to operate acutely. CONCLUSIONS Early LC is clearly superior to delayed LC in acute cholecystitis. The most recent evidence-based practice strongly suggests that early LC should be standard of care in the management of acute cholecystitis.
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Gibbons G, Tan CJ, Bartolo DCC, Filgate R, Makin G, Barwood N, Wallace M. Emergency left colonic resections on an acute surgical unit: does subspecialization improve outcomes? ANZ J Surg 2015; 85:739-43. [DOI: 10.1111/ans.13160] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Genevieve Gibbons
- Department of General Surgery; Fremantle Hospital; Fremantle Western Australia Australia
| | - Chuan Jin Tan
- Department of General Surgery; Fremantle Hospital; Fremantle Western Australia Australia
| | - David C. C. Bartolo
- Department of General Surgery; Fremantle Hospital; Fremantle Western Australia Australia
| | - Rhys Filgate
- Department of General Surgery; Fremantle Hospital; Fremantle Western Australia Australia
| | - Greg Makin
- Department of General Surgery; Fremantle Hospital; Fremantle Western Australia Australia
| | - Nigel Barwood
- Department of General Surgery; Fremantle Hospital; Fremantle Western Australia Australia
| | - Marina Wallace
- Department of General Surgery; Fremantle Hospital; Fremantle Western Australia Australia
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Early Cholecystectomy Is Superior to Delayed Cholecystectomy for Acute Cholecystitis: a Meta-analysis. J Gastrointest Surg 2015; 19:848-57. [PMID: 25749854 DOI: 10.1007/s11605-015-2747-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 01/07/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The timing of laparoscopic cholecystectomy for acute cholecystitis remains an issue for debate amongst general surgeons. The aim of this study was to compare clinical outcomes between early and delayed cholecystectomy for acute cholecystitis. The primary outcome measures included mortality rates, complication rates, length of hospital stay and conversion rates to open procedures. MATERIALS AND METHODS A search of electronic databases was performed for randomised controlled trials. Fifteen studies were included. RESULTS Early surgery has a decreased risk of wound infections (RR 0.57, 95 % CI 0.35-0.93, p=0.01) compared with delayed surgery but no difference in mortality, bile duct injuries, bile duct leaks and the risk of conversion to open surgery. Of patients in the delayed group, 9.7 % failed initial non-operative management and underwent emergency LC. Early surgery had a significantly reduced total hospital stay and mean hospital costs compared with delayed surgery. CONCLUSION Early laparoscopic cholecystectomy in acute cholecystitis demonstrated decreased incidence of wound infections, a shorter total length of stay and decreased costs with no difference in the rates of mortality, bile duct injuries, bile leaks and conversions. These results support that early laparoscopic cholecystectomy is the best care and should be considered a routine in patients presenting with acute cholecystitis.
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Dobson H, Ranasinghe WK, Hong MK, Bray LN, Sathveegarajah M, Vally F, Miller FJ. Waiting for definitive care: An analysis of elapsed time from decision to surgery or transfer in a rural centre. Aust J Rural Health 2015; 23:155-60. [DOI: 10.1111/ajr.12160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Hannah Dobson
- Department of Surgery; Northeast Health Wangaratta; Wangaratta Victoria Australia
| | | | - Matthew K.H. Hong
- Department of Surgery; Northeast Health Wangaratta; Wangaratta Victoria Australia
| | - Liliana N. Bray
- Department of Surgery; Northeast Health Wangaratta; Wangaratta Victoria Australia
| | | | - Fatima Vally
- Department of Surgery; Northeast Health Wangaratta; Wangaratta Victoria Australia
| | - Francis J. Miller
- Department of Surgery; Northeast Health Wangaratta; Wangaratta Victoria Australia
- Rural Health Academic Centre; Melbourne University; Melbourne Victoria Australia
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Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 2015; 263:20-7. [PMID: 25742461 DOI: 10.1097/sla.0000000000001180] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The use of laparoscopy for liver surgery is increasing rapidly. The Second International Consensus Conference on Laparoscopic Liver Resections (LLR) was held in Morioka, Japan, from October 4 to 6, 2014 to evaluate the current status of laparoscopic liver surgery and to provide recommendations to aid its future development. Seventeen questions were addressed. The first 7 questions focused on outcomes that reflect the benefits and risks of LLR. These questions were addressed using the Zurich-Danish consensus conference model in which the literature and expert opinion were weighed by a 9-member jury, who evaluated LLR outcomes using GRADE and a list of comparators. The jury also graded LLRs by the Balliol Classification of IDEAL. The jury concluded that MINOR LLRs had become standard practice (IDEAL 3) and that MAJOR liver resections were still innovative procedures in the exploration phase (IDEAL 2b). Continued cautious introduction of MAJOR LLRs was recommended. All of the evidence available for scrutiny was of LOW quality by GRADE, which prompted the recommendation for higher quality evaluative studies. The last 10 questions focused on technical questions and the recommendations were based on literature review and expert panel opinion. Recommendations were made regarding preoperative evaluation, bleeding controls, transection methods, anatomic approaches, and equipment. Both experts and jury recognized the need for a formal structure of education for those interested in performing major laparoscopic LLR because of the steep learning curve.
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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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O'Leary DP, Beecher S, McLaughlin R. Emergency surgery pre-operative delays - realities and economic impacts. Int J Surg 2014; 12:1333-6. [PMID: 25462705 DOI: 10.1016/j.ijsu.2014.10.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 09/18/2014] [Accepted: 10/04/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND A key principle of acute surgical service provision is the establishment of a distinct patient flow process and an emergency theatre. Time-to-theatre (TTT) is a key performance indicator of theatre efficiency. The combined impacts of an aging population, increasing demands and complexity associated with centralisation of emergency and oncology services has placed pressure on emergency theatre access. We examined our institution's experience with running a designated emergency theatre for acute surgical patients. METHODS A retrospective review of an electronic prospectively maintained database was performed between 1/1/12 and 31/12/13. A cost analysis was conducted to assess the economic impact of delayed TTT, with every 24hr delay incurring the cost of an additional overnight bed. Delays and the economic effects were assessed only after the first 24 h as an in-patient had elapsed. RESULTS In total, 7041 procedures were performed. Overall mean TTT was 26 h, 2 min. There were significant differences between different age groups, with those aged under 16 year and over 65 having mean TTT at 6 h, 34 min (95% C.I. 0.51-2.15, p < 0.001) and 23 h, 41 min (95% C.I. 19.6-23.9, p < 0.001) respectively. 2421 (34%) waited greater than 24 h for emergency procedures. The >65 years age group had a mean TTT of 23 h, 41 min which was significantly longer than the overall mean TTT Vascular and urological emergencies are significantly disadvantaged in competition with other services for a shared emergency theatre. The economic impact of delayed TTT was calculated at €7,116,000, or €9880/day of additional costs generated from delayed TTT over a 24 month period. CONCLUSION One third of patients waited longer than 24 h for emergency surgery, with the elderly disproportionately represented in this group. Aside from the clinical risks of delayed and out of hours surgery, such practices incur significant additional costs. New strategies must be devised to ensure efficient access to emergency theatres, investment in such services is likely to be financially and clinically beneficial.
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Affiliation(s)
- D P O'Leary
- Department of Surgery, Galway University Hospital, National University of Ireland (NUI), Galway, Ireland.
| | - S Beecher
- Department of Surgery, Galway University Hospital, National University of Ireland (NUI), Galway, Ireland
| | - R McLaughlin
- Department of Surgery, Galway University Hospital, National University of Ireland (NUI), Galway, Ireland
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Poh BR, Cashin P, Dubrava Z, Blamey S, Yong WW, Croagh DG. Impact of an acute care surgery model on appendicectomy outcomes. ANZ J Surg 2014; 83:735-8. [PMID: 24099125 DOI: 10.1111/ans.12351] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Monash Medical Centre introduced the acute surgical unit (ASU) in July 2011. The ASU is modelled on the concept of acute care surgery (ACS). This study reviews the impact of the ASU on the outcomes in an appendicectomy population. METHODS A retrospective review of all patients (aged 16-99 years) who underwent appendicectomies in the 2-year study time frame (from July 2010 to June 2012) at our centre was performed. The cohort (n = 539) was divided into two groups for analysis: the ASU group, patients admitted on or after 18 July 2011 (n = 283), and the control group, patients admitted prior to 18 July 2011 (n = 256). RESULTS Median time to operation (1129 min versus 1080 min, P = 0.963) and negative appendicectomy rate (24.2% versus 24.8%, P = 0.871) were similar in both groups. The proportion of operations performed overnight (18.00-08.00 hours) was significantly decreased in the ASU group (17.1% versus 30.7%, P < 0.001). Perforation rate was marginally higher in the ASU group (17.8% versus 11.8%, P = 0.053) but failed to reach statistical significance. There was an increase in the usage of preoperative imaging (40.3% versus 30.5%, P = 0.018) in the ASU group. Operating times, length of stay, laparoscopic-to-open conversion and surgical site infection rates remained similar. CONCLUSION We conclude that implementation of an ACS model does not lead to objective differences in outcome for patients after appendicectomy. However, the ACS model significantly decreased the number of operations performed after-hours.
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Affiliation(s)
- Benjamin Ruimin Poh
- Department of Upper GI/HPB Surgery, Monash Medical Centre, Melbourne, Victoria, Australia; Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Pillai S, Hsee L, Pun A, Mathur S, Civil I. Comparison of appendicectomy outcomes: acute surgical versus traditional pathway. ANZ J Surg 2014; 83:739-43. [PMID: 24099126 DOI: 10.1111/ans.12350] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2013] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The acute surgical unit (ASU) is an evolving novel concept introduced to address the challenge of maintaining key performance indicators (KPIs) in the face of an increasing acute workload. METHODS The aim of this retrospective study was to compare the performance of the ASU (from June 2008 to December 2010) at Auckland City Hospital with the traditional model (from January 2006 to May 2008) and benchmark the results against other similar published studies. The analysis was on the basis of KPIs for 1857 appendicectomies, which form a large volume of acute surgical presentations. RESULTS Our results show significant improvement in length of stay (2.8 days, 2.6 days, P = 0.0001) and proportion of daytime operations (59.4%, 65.8%, P = 0.004), in keeping with other studies on benchmarking. CONCLUSION The introduction of ASU has led to significant improvements in some KPIs for appendicectomy outcomes in the face of an increasing workload.
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Affiliation(s)
- Sandhya Pillai
- Acute Surgical Unit, Department of Surgery, Auckland City Hospital, Auckland, New Zealand
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Anantha RV, Parry N, Vogt K, Jain V, Crawford S, Leslie K. Implementation of an acute care emergency surgical service: a cost analysis from the surgeon's perspective. Can J Surg 2014; 57:E9-14. [PMID: 24666462 DOI: 10.1503/cjs.001213] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Acute care surgical services provide comprehensive emergency general surgical care while potentially using health care resources more efficiently. We assessed the volume and distribution of emergency general surgery (EGS) procedures before and after the implementation of the Acute Care and Emergency Surgery Service (ACCESS) at a Canadian tertiary care hospital and its effect on surgeon billings. METHODS This single-centre retrospective case-control study compared adult patients who underwent EGS procedures between July and December 2009 (pre-ACCESS), to those who had surgery between July and December 2010 (post-ACCESS). Case distribution was compared between day (7 am to 3 pm), evening (3 pm to 11 pm) and night (11 pm to 7 am). Frequencies were compared using the χ(2) test. RESULTS Pre-ACCESS, 366 EGS procedures were performed: 24% during the day, 55% in the evening and 21% at night. Post-ACCESS, 463 operations were performed: 55% during the day, 36% in the evening and 9% at night. Reductions in night-time and evening EGS were 57% and 36% respectively (p < 0.001). Total surgeon billings for operations pre- and post-ACCESS were $281 066 and $287 075, respectively: remuneration was $6008 higher post-ACCESS for an additional 97 cases (p = 0.003). Using cost-modelling analysis, post-ACCESS surgeon billing for appendectomies, segmental colectomies, laparotomies and cholecystectomies all declined by $67 190, $125 215, $66 362, and $84 913, respectively (p < 0.001). CONCLUSION Acute care surgical services have dramatically shifted EGS from nighttime to daytime. Cost-modelling analysis demonstrates that these services have cost-savings potential for the health care system without reducing overall surgeon billing.
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Affiliation(s)
- Ram Venkatesh Anantha
- The Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont
| | - Neil Parry
- The Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont., and The Division of Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont
| | - Kelly Vogt
- The Division of Acute Care Surgery and Surgical Critical Care, Los Angeles County and University of Southern California Medical Center, Los Angeles, Calif
| | - Vipan Jain
- Strathroy Middlesex General Hospital, Strathroy, Ont
| | - Silvie Crawford
- The Division of General Surgery, University of Western Ontario, London, Ont
| | - Ken Leslie
- The Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont
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Sandbaek BE, Helgheim BI, Larsen OI, Fasting S. Impact of changed management policies on operating room efficiency. BMC Health Serv Res 2014; 14:224. [PMID: 24885869 PMCID: PMC4032582 DOI: 10.1186/1472-6963-14-224] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 05/12/2014] [Indexed: 11/24/2022] Open
Abstract
Background To increase operating room (OR) efficiency, a new resource allocation strategy, a new policy for patient urgency classification, and a new system for OR booking was implemented at a tertiary referral hospital. We investigated the impact of these interventions. Methods We carried out a before-and-after study using OR data. A total of 23 515 elective (planned) and non-elective (unplanned) orthopaedic and general surgeries were conducted during calendar year 2007 (period 1) and July 2008 to July 2009 (period 2). The Wilcoxon–Mann–Whitney test was used to calculate statistical significance. Results An increased amount of case time (7.1%, p < 0.05) was conducted without any increase in out-of-hours case time. Despite having three fewer ORs for electives, slightly more elective case time was handled with 26% less use of overtime (p < 0.05). Mean OR utilization was 56% for the 17 mixed ORs, 60% for the 14 elective ORs, and 62% for the 3 dedicated ORs. A 20% growth (p < 0.05) of non-elective case time was primarily absorbed through enhanced daytime surgery, which increased over 48% (p < 0.05). As a result, the proportions of case time on evenings and nights decreased. Specifically, case time at night decreased by 26% (p < 0.05), and the number of nights without surgery increased from 55 to 112 (out of 315 and 316, respectively). Median waiting time for the middle urgencies increased with 1.2 hours, but over 90% received treatment within maximum acceptable waiting time (MAWT) in both periods. Median waiting time for the lowest urgencies was reduced with 12 hours, and the proportion of cases treated within MAWT increased from 70% to 89%. The proportion of high urgency patients (as a proportion of the total) was reduced from 20% to 12%. Consequently, almost 90% of the operations could be planned at least 24 hours in advance. Conclusions The redesign facilitated effective daytime surgery and a more selective use of the ORs for high urgency patients out of hours. The synergistic effect probably exceeded the sum of the individual effects of the changes, because the effects of each intervention facilitated the successful implementation of others.
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Affiliation(s)
- Birgithe E Sandbaek
- Faculty of Economics, Informatics and Social Sciences, Molde University College, Specialized University in Logistics, PB 2110, 6402 Molde, Norway.
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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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Introduction of an Acute Surgical Unit: Comparison of Performance Indicators and Outcomes for Operative Management of Acute Appendicitis. World J Surg 2014; 38:1947-53. [PMID: 24682310 DOI: 10.1007/s00268-014-2497-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Anantha RV, Brackstone M, Parry N, Leslie K. An acute care surgery service expedites the treatment of emergency colorectal cancer: a retrospective case-control study. World J Emerg Surg 2014; 9:19. [PMID: 24656174 PMCID: PMC3994420 DOI: 10.1186/1749-7922-9-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/18/2014] [Indexed: 02/07/2023] Open
Abstract
Introduction Emergency colorectal cancer (CRC) is a complex disease that requires multidisciplinary approaches for management. However, it is unclear whether acute care surgery (ACS) services can expedite the workup and treatment of complex surgical diseases such as emergency CRC. We sought to assess the impact of an Acute Care and Emergency Surgery Service (ACCESS) on wait-times for inpatient colonoscopy and surgical resection among emergency CRC patients. Methods This retrospective case–control study was conducted at a tertiary-care, university-affiliated, cancer centre in London, Ontario, Canada. All patients aged 18 or older who presented to the emergency department with a recent (within 48 hours) diagnosis of CRC, or were diagnosed with CRC after admission, were included in the study. Patients were either in the pre-ACCESS (July 1, 2007-June 31, 2010) or post-ACCESS (July 1, 2010-June 30, 2012) groups. A third group of emergency CRC patients treated at an adjacent cancer centre that lacked ACCESS (non-ACCESS) was evaluated separately. The primary outcome was time from admission to colonoscopy and surgery. Results A total of 149 patients (47 pre-ACCESS, 37 post-ACCESS, and 65 non-ACCESS) were identified. Only 19% (n = 9) of pre-ACCESS patients underwent inpatient colonoscopy, compared to 38% (n = 14) in the post-ACCESS group (p = 0.023). Additionally, 100% of patients in the post-ACCESS era underwent inpatient colonoscopy and surgery during the same admission, compared to only 44% of pre-ACCESS patients (p = 0.006). Median wait-times for inpatient colonoscopy (2.0 and 1.8 days for pre- and post-ACCESS groups respectively, p = 0.08) and surgical resection (1.6 and 2.3 days for pre- and post-ACCESS groups respectively, p = 0.40) were similar. Conclusions Patients admitted to ACCESS underwent more inpatient colonoscopies and were more likely to have definitive surgery on that admission. ACS services can facilitate the workup and management of complex surgical diseases such as emergency CRC without delaying treatment.
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Affiliation(s)
| | | | | | - Ken Leslie
- Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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Provision of acute general surgery: a systematic review of models of care. J Trauma Acute Care Surg 2014; 76:219-25. [PMID: 24368384 DOI: 10.1097/ta.0b013e3182a92481] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This article systematically reviews currently available models in Europe, the United Kingdom, Australia and New Zealand for the provision of acute general surgical service and acute care surgery. METHOD Four hundred and thirty eight articles were identified in a literature search. Of these, 13 were included within the systematic review. RESULTS Each acute care model is unique to its local and regional setting but all models have common goals. These include being consultant led, adequate resourcing with junior medical staff, theatre space and anaesthetic support and no competing elective surgical or out-patient commitments. All models require an individual, service and institutional commitment to prioritising the assessment and treatment of acute surgical patients and are characterised by uninterrupted periods of work focussed on the care of acute surgical patients supported by comprehensive patient handover to maintain safe staff working hours. CONCLUSION The provision of acute care for surgical patients is a fundamental role of general surgeons. With the diverse demands on surgeons of teaching, research, elective surgery and patient assessments as well as a family and lifestyle obligations newer systems of service provision based on collective, rather than individualised service commitment, are being developed. These systems emphasise discrete periods of defined service without elective surgical commitments with formal and structured surgeon to surgeon handover. Initial experience indicates that patient care is satisfactory, continuity of care is maintained, and acute care pathways function efficiently. LEVEL OF EVIDENCE Systematic review, level IV.
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Page DE, Dooreemeah D, Thiruchelvam D. Acute surgical unit: the Australasian experience. ANZ J Surg 2013; 84:25-30. [DOI: 10.1111/ans.12473] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 12/20/2022]
Affiliation(s)
- Dean E. Page
- Department of Surgery; St Vincent's Hospital; Melbourne Victoria Australia
| | - Dilshad Dooreemeah
- Department of Surgery; St Vincent's Hospital; Melbourne Victoria Australia
| | - Dhan Thiruchelvam
- Department of Surgery; St Vincent's Hospital; Melbourne Victoria Australia
- Department of Surgery; Epworth Hospital; Melbourne Victoria Australia
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Suen K, Hayes IP, Thomson BNJ, Shedda S. Effect of the introduction of an emergency general surgery service on outcomes from appendicectomy. Br J Surg 2013; 101:e141-6. [DOI: 10.1002/bjs.9320] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2013] [Indexed: 12/16/2022]
Abstract
Abstract
Background
Appendicectomy is a common general surgical emergency procedure and may be used as a surrogate marker to evaluate quality in surgical management. The aim of this study was to assess the outcomes of appendicectomy before and after the introduction of a consultant-led emergency general surgery (EGS) service at a large metropolitan tertiary referral centre.
Methods
A retrospective historical control study was performed that included all adult patients undergoing appendicectomy during two 18-month periods, before and after the introduction of the EGS service. Data collected included patient demographics, use of radiological investigations, time to surgery, length of hospital stay and histopathology findings. Outcome measures were time to surgery, hospital length of stay, use of radiological investigations, negative appendicectomy rate and perforation rate.
Results
A total of 675 patients were identified of whom 276 had an appendicectomy before the EGS service was introduced (2008–2009) and 399 after its introduction (2011–2012). The EGS service resulted in an increase in time to surgery (15 versus 18 h; P < 0·001) with no increase in length of hospital stay (3 days for both periods; P = 0·424). An increase in the rate of appendicectomies performed within office hours was seen (54·3 versus 64·4 per cent; P < 0·001), with no significant increase in negative appendicectomy (13·0 versus 15·8 per cent; P = 0·322) or perforation (8·3 versus 5·5 per cent; P = 0·149) rates. The use of preoperative computed tomography reduced from 38·4 to 26·6 per cent (P = 0·001).
Conclusion
The introduction of a consultant-led EGS service resulted in a decrease in the use of computed tomography and a greater proportion of appendicectomies performed within office hours, with no increase in length of stay. Overall negative appendicectomy and perforation rates did not change.
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Affiliation(s)
- K Suen
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - I P Hayes
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - B N J Thomson
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - S Shedda
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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