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Jain S, Puranik A. Trauma and Emergency Surgery: Conceptual Framework, Dedicated Distinctiveness, and Dignification. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03796-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/25/2023] [Indexed: 09/12/2023] Open
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Ong MW, Goh SSN, Tung WMJ, Lim WW, Hu HH, Lim CY, Ng P, Tan KY, Goo TTJ. Initial emergency laparotomy outcomes following a transdisciplinary perioperative care pathway in Singapore. Acute Med Surg 2021; 8:e702. [PMID: 34745640 PMCID: PMC8552521 DOI: 10.1002/ams2.702] [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: 05/14/2021] [Revised: 09/03/2021] [Accepted: 10/07/2021] [Indexed: 11/10/2022] Open
Abstract
Aim Emergency laparotomy (EL) is a common surgery associated with high morbidity and mortality. An enhanced care pathway incorporates evidence-based care bundles with the aim of providing standardized perioperative care. Prior to 2019, EL management in our institution was not standardized. This study aims to assess whether implementation of a transdisciplinary perioperative Emergency Laparotomy (ELAP) pathway improves clinical and efficiency outcomes of EL. Methods A prospective single-center audit was undertaken between 1 January and 31 December, 2019 following the implementation of the ELAP pathway. Comparisons were made with retrospective data from the preimplementation period between 1 January and 31 December, 2017. Demographics and clinical and efficiency outcomes were compared for patients (age > 16 years old) requiring EL for acute abdominal conditions. Results There were 152 and 162 patients from preimplementation and postimplementation periods, respectively. There was a nonsignificant reduction of 30-day mortality in the intervention group receiving perioperative pathway care compared with the preintervention group (3.1% versus 5.3%, respectively; P = 0.40). There was a decrease in postoperative complications in the intervention group, in particular for Clavien-Dindo IV complications (11.2% versus 3.1%, p < 0.01). Efficiency outcomes improved postimplementation with increased consultant surgeon and anesthetist presence in operating theater and postoperative geriatric assessment for elderly patients. There was an overall reduction in cost of hospital stay from S$32,128 to $27,947 (p = 0.24). Conclusion Implementation of a transdisciplinary perioperative care pathway was associated with significant reduction in postoperative complications, improvement in 30-day mortality and efficiency outcomes at reduced hospital costs for patients following EL in our institution.
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Affiliation(s)
- Marc Weijie Ong
- Department of General Surgery Khoo Teck Puat Hospital Singapore City Singapore
| | - Serene Si Ning Goh
- Department of General Surgery Khoo Teck Puat Hospital Singapore City Singapore
| | - Wei Min James Tung
- Lee Kong Chian School of Medicine Nanyang Technological University Singapore City Singapore
| | - Woan Wui Lim
- Department of General Surgery Khoo Teck Puat Hospital Singapore City Singapore
| | - Hilda Haoling Hu
- Department of Anaesthesia Khoo Teck Puat Hospital Singapore City Singapore
| | - Choong Yan Lim
- Department of Geriatric Medicine Khoo Teck Puat Hospital Singapore City Singapore
| | - Priscilla Ng
- Department of Geriatric Medicine Khoo Teck Puat Hospital Singapore City Singapore
| | - Kok Yang Tan
- Department of General Surgery Khoo Teck Puat Hospital Singapore City Singapore
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Sarmiento Altamirano D, Himmler A, Chango Sigüenza O, Pino Andrade R, Flores Lazo N, Reinoso Naranjo J, Sacoto Aguilar H, Fernández de Córdova L, Rodas E, Puyana JC, Salamea Molina JC. The Successful Implementation of a Trauma and Acute Care Surgery Model in Ecuador. World J Surg 2021; 44:1736-1744. [PMID: 32107595 DOI: 10.1007/s00268-020-05435-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND For years, surgical emergencies in Ecuador were managed on a case-by-case basis without significant standardization. To address these issues, the Regional Hospital Vicente Corral Moscoso adapted and implemented a model of "trauma and acute care surgery" (TACS) to the reality of Cuenca, Ecuador. METHODS A cohort study was carried out, comparing patients exposed to the traditional model and patients exposed to the TACS model. Variables assessed included number of surgical patients attended to in the emergency department, number of surgical interventions, number of surgeries performed per surgeon, surgical wait time, length of stay and in-hospital mortality. RESULTS The total number of surgical interventions increased (3919.6-5745.8, p ≤ 0.05); by extension, the total number of surgeries performed per surgeon also increased (5.37-223.68, p ≤ 0.05). We observed a statistically significant decrease in surgical wait time (10.6-3.2 h for emergency general surgery, 6.3-1.6 h for trauma, p ≤ 0.05). Length of stay decreased in trauma patients (9-6 days, p ≤ 0.05). Higher mortality was found in the traditional model (p ≤ 0.05) compared to the TACS model. CONCLUSIONS The implementation of TACS model in a resource-restrained hospital in Latin America had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients and length of stay in trauma patients. We also noted a statistically significant decrease in mortality. Savings to the overall system and patients can be inferred by decreased mortality, length of stay and surgical wait times. To our knowledge, this is the first implementation of a TACS model described in Latin America.
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Affiliation(s)
| | - Amber Himmler
- Division of Surgery, Medstar Georgetown University Hospital and Washington Hospital Center, Washington, DC, USA. .,University of Pittsburgh, Pittsburgh, PA, USA.
| | - Oscar Chango Sigüenza
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Raúl Pino Andrade
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad de Cuenca, Cuenca, Ecuador
| | - Nube Flores Lazo
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad de Cuenca, Cuenca, Ecuador
| | - Jeovanni Reinoso Naranjo
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad de Cuenca, Cuenca, Ecuador
| | - Hernán Sacoto Aguilar
- Facultad de Medicina, Universidad de Azuay, Cuenca, Ecuador.,Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Lenin Fernández de Córdova
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad Católica de Cuenca, Cuenca, Ecuador
| | - Edgar Rodas
- Division of Trauma and Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Juan Carlos Puyana
- Division of Trauma and Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Juan Carlos Salamea Molina
- Facultad de Medicina, Universidad de Azuay, Cuenca, Ecuador.,Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
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Mathur S, Jeremy Ng CF, Koh F, Cai M, Palaniappan G, Linn YL, Lim HL, Lakshman R, Ling XS, Chin ST, Tan HK. Development of an enhanced acute care surgery service in response to the COVID-19 global pandemic. Injury 2020; 51:2135-2141. [PMID: 32605788 PMCID: PMC7315164 DOI: 10.1016/j.injury.2020.06.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND As the COVID-19 pandemic sweeps across the world, healthcare departments must adapt to meet the challenges of service provision and staff/patient protection. Unlike elective surgery, acute care surgery (ACS) workloads cannot be artificially reduced providing a unique challenge for administrators to balance healthcare resources between the COVID-19 surge and regular patient admissions. METHODS An enhanced ACS (eACS) model of care is described with the aim of limiting COVID-19 healthcare worker and patient cross-infection as well as providing 24/7 management of emergency general surgical (GS) and trauma patients. The eACS service comprised 5 independent teams covering a rolling 1:5 24-hr call. Attempts to completely separate eACS teams and patients from the elective side were made. The service was compared to the existing ACS service in terms of clinical and efficiency outcomes. Finally, a survey of staff attitudes towards these changes, concerns regarding COVID-19 and psychological well-being was assessed. RESULTS There were no staff/patient COVID-19 cross-infections. Compared to the ACS service, eACS patients had reduced overall length of stay (2-days), time spent in the Emergency Room (46 min) and time from surgery to discharge (2.4-hours). The eACS model of care saved financial resources and bed-days for the organisation. The changes were well received by team-members who also felt that their safety was prioritised. CONCLUSION In healthcare systems not overwhelmed by COVID-19, an eACS model may assist in preserving psychological well-being for healthcare staff whilst providing 24/7 care for emergency GS and trauma patients.
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Affiliation(s)
- Sachin Mathur
- Department of General Surgery, Singapore General Hospital, 169608 Singapore,Corresponding author at: Trauma and Acute Care Surgeon, Singapore General Hospital, Outram Road Singapore
| | | | - Fangju Koh
- Department of General Surgery, Singapore General Hospital, 169608 Singapore
| | - Mingzhe Cai
- Department of General Surgery, Singapore General Hospital, 169608 Singapore
| | | | - Yun Le Linn
- Department of General Surgery, Singapore General Hospital, 169608 Singapore
| | - Huiling Linda Lim
- Department of General Surgery, Singapore General Hospital, 169608 Singapore
| | - Ramu Lakshman
- Department of General Surgery, Singapore General Hospital, 169608 Singapore
| | - Xiao Shuang Ling
- Department of General Surgery, Singapore General Hospital, 169608 Singapore
| | - Sock Teng Chin
- Department of General Surgery, Singapore General Hospital, 169608 Singapore
| | - Hiang Khoon Tan
- Division of Surgery and Surgical Oncology, Singapore General Hospital and National Cancer Centre Singapore, Singhealth Duke-NUS Head and Neck Centre, Singapore
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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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Goh SNS, Lim WW, Rao AD, Mathur S, Tan KY, Goo TTJ. Evolution of a Dedicated Emergency Surgery and Trauma (ESAT) unit over 3 years: sustained improved outcomes. Eur J Trauma Emerg Surg 2018; 46:627-633. [PMID: 30448944 DOI: 10.1007/s00068-018-1049-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 11/13/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The traditional 24-h call model faces pressure from competing needs between emergency and elective services. Recognizing this, a dedicated ESAT service was developed in Khoo Teck Puat Hospital in Singapore, with improved clinical outcomes. It was initially led by a single consultant (SC) in 2014, and subsequently evolved to a weekly consultant rotation (WC) roster in 2017 to achieve sustainability. METHODS Each consultant led the ESAT WC service for a week and maintained ownership of their patients thereafter. All emergency surgical admissions between two distinct 6-month periods were reviewed, from May to October 2014 (pre-ESAT) and January to June 2017 (ESAT WC). Patient demographics, diagnoses, and operations were compared. Efficiency and clinical outcomes were evaluated. RESULTS There were 1248 and 1284 patients in the pre-ESAT and ESAT WC group, respectively. Majority were males and in their 50s. Acute appendicitis, gallstone conditions, and soft-tissue infections made up half of the admissions. Trauma workload was comparable (7.8% pre-ESAT vs 9.5% ESAT WC). Cholecystectomies doubled during the ESAT period, 14.2% vs 7.2%, (p = 0.01). More consultants were involved in major cases (95.9% vs 86%), (p = 0.01) and more operations were performed during the day (52.1% vs 47.9%), (p = 0.01). Average time to OT was shorter and there were less major surgical complications (p = 0.02). Mortality (p = 0.08) and length of stay were reduced (4 vs 4.5 days), (p = 0.01). CONCLUSION The ESAT WC service has sustained improved outcomes in our institution.
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Affiliation(s)
- Si Ning Serene Goh
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore.
| | - Woan Wui Lim
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Anil Dinker Rao
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Sachin Mathur
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Kok Yang Tan
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
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Aranda-Narváez JM, Tallón-Aguilar L, López-Ruiz JA, Pareja-Ciuró F, Jover-Navalón JM, Turégano-Fuentes F, Navarro-Soto S, Ceballos-Esparragón J, Pérez-Díaz L. The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain. Cir Esp 2018; 97:3-10. [PMID: 30415793 DOI: 10.1016/j.ciresp.2018.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023]
Abstract
The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lola Pérez-Díaz
- Hospital General Universitario Gregorio Marañón, Madrid, España
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Mathur S, Lim WW, Goo TT. Emergency general surgery and trauma: Outcomes from the first consultant-led service in Singapore. Injury 2018; 49:130-134. [PMID: 28899559 DOI: 10.1016/j.injury.2017.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/29/2017] [Accepted: 09/01/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is a significant burden on public health systems from emergency surgical and trauma (ESAT) patients. In Western countries, the response has been to separate acute and elective surgery with the creation of a new sub-specialty: acute care surgery. Dedicated acute units have shown improvements in efficiency and clinical outcomes for patients. The aim of this study was to assess the results of the first such unit in Singapore. MATERIALS AND METHODS A retrospective analysis was performed of a 12-month period of acute admissions between May 2014 and April 2015, with comparison of 6-months before and after the creation of the ESAT service. The ESAT service was a consultant led dedicated team managing all daily acute and trauma patients. Demographic, efficiency and clinical outcome key performance indicators were compared. RESULTS There were 2527 acute admissions split between the two time periods. The ESAT service (N=1279) managed soft tissue infections (257, 20%), appendicitis (199, 16%) and biliary disease (175, 14%) most commonly. The most common of the 573 procedures performed were incision and drainage (242, 42%), appendicectomy (188, 33%) and laparotomy (84, 16%). Clinical outcome during the ESAT service included reduction in overall mean length of stay (4.5d to 3.5d, P<0.01) and mortality (24/1248 (1.9%) to 11/1279 (0.9%), P=0.03). Efficiency gains in theatre booking time, ED surgical review and overall costs were also noted. CONCLUSION The creation of an ESAT service has led to improved efficiency of care with no worsening of clinical outcomes for acute general surgical and trauma patients.
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Affiliation(s)
- Sachin Mathur
- Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
| | - Woan Wui Lim
- Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
| | - Tiong Thye Goo
- Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
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Dickfos M, Ibrahim H, Evans A, Franz R. Cohort study on emergency general surgery patients and an observation unit. ANZ J Surg 2017; 88:713-717. [PMID: 28370979 DOI: 10.1111/ans.13960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/27/2017] [Accepted: 02/08/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Medium-sized, non-trauma hospitals experience many of the same difficulties as tertiary centres do when it comes to managing emergency general surgery patients. However, acute surgical units are not a financially viable option in these hospitals. To improve the care of emergency general surgery patients at one such hospital, a Rapid Assessment Medical Surgical (RAMS) unit was developed to decrease the time to review and increase the efficiency in caring for these patients. METHODS To assess the unit's effect, a prospective analysis was completed of the patients who came through the RAMS unit over a 6-month period and compared with a retrospective analysis of patients presenting in the same 6-month period the year prior to the unit's instigation. RESULTS The RAMS unit was effective in providing an avenue for faster review by the surgical team. This resulted in patients leaving the emergency department faster, decreased the number of patients that breached emergency department time-targets and increased the number of patients discharged after a period of observation or basic treatments. CONCLUSION General surgery patients were managed more efficiently with the RAMS unit in place. However, a full cost analysis is required to determine if such units are cost-effective.
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Affiliation(s)
- Marilla Dickfos
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Hany Ibrahim
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Andrew Evans
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Robert Franz
- Department of General Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia
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