outcomes in emergency general surgery following the introduction of a consultant-led unit

7212019 Outcomes in Emergency General Surgery Following the Introduction of a Consultant-led Unit

httpslidepdfcomreaderfulloutcomes-in-emergency-general-surgery-following-the-introduction-of-a-consultant-led 17

Original article

Outcomes in emergency general surgery following the

introduction of a consultant-led unit

R Shakerian

12

B N Thomson

12

A Gorelik

3

I P Hayes

12

and A R Skandarajah

12

1Department of General Surgical Specialties 2 Department of Surgery University of Melbourne and 3 Melbourne EpiCentre Centre for Clinical

Epidemiology Biostatistics and Health Services Research (University of Melbourne and Melbourne Health) The Royal Melbourne Hospital Parkville

Victoria Australia

Correspondence to Miss R Shakerian Department of General Surgical Specialties Level 2 East The Royal Melbourne Hospital 300 Grattan Street

Parkville Victoria 3050 Australia (e-mail shakerianrosegmailcom)

Background Patients presenting with emergency surgical conditions place signi1047297cant 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 2009ndash2012 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 sdot6

per cent increase) and performed 1804 operations (41sdot0 per cent increase) The most com-

mon diagnoses during the EGS period included acute appendicitis (532 11sdot9 per cent) bil-

iary disease (361 8sdot1 per cent) and abdominal pain (561 12sdot6 per cent) Appendicectomy (536

29sdot7 per cent) cholecystectomy (239 13sdot2 per cent) and laparotomy (226 12sdot5 per cent) were

the most commonly performed procedures In the EGS period time in the emergency depart-

ment was reduced (from 8sdot0 t o 6sdot0 h P lt0sdot001) as was length of hospital stay (from 3sdot0 to

2sdot0 days P lt0sdot001) The number of complications was reduced by 46sdot8 per cent from 172 (6sdot2

per cent) to 147 (3sdot3 per cent) ( P lt0sdot001) with a 53 per cent reduction in the number of deaths in

the EGS period from 29 (16sdot

9 per cent) to seven (8 per cent) ( P =

0sdot

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

Preliminary results presented to the Annual Scientific Congress of the Royal Australasian College of SurgeonsSingapore May 2014

Paper accepted 27 August 2015

Published online 22 October 2015 in Wiley Online Library (wwwbjscouk) DOI 101002bjs9954

Introduction

Emergency general surgical patients form a substantial

proportion of hospital admissions globally 1 In generalemergency conditions account for more than one-third of

all general surgical admissions2ndash 4

The growing and ageing population rise in complex

and chronic illnesses and increasing rates of trauma have

been the main contributors to the increased demand for

emergency surgery Several countries have experienced

an increase in the number of emergency general surgery

(EGS) admissions with the burden of these conditions

far exceeding that of many other common public health

problems5

In Australia health services have the additional challengeof needing to meet government-initiated health targets

such as elective surgery waiting lists and the National

Emergency Access Target (NEAT) for patient throughput

in emergency departments6 A proportion of EGS ser-

vices in Australia have been redesigned with the aim of

providing timely and efficient emergency care Although

models of care vary owing to local needs and resources

the majority of services are consultant-led A number of

copy 2015 BJS Society Ltd BJS 2015 102 1726ndash1732Published by John Wiley amp Sons Ltd



Outcomes in an emergency general surgery service 1727

studies7ndash 16 have evaluated the impact of new models of EGS care on patient outcomes Owing to their prevalenceas common emergency conditions acute appendicitis andbiliary disease have been the focus of most studies compar-ing traditional models of care with the new models 1017 ndash21

The impact on administrative and clinical outcomeshas been assessed predominantly in the context of thesetwo conditions with only a few studies analysing theimpact on the entire cohort of emergency general surgicaladmissions

The aim of the present study was to determine the impact of an EGS service on the management of all emergency general surgical patients Outcomes such as emergency department and hospital length of stay as well as theoverall rate of complications were included In additionthe complication rate for patients undergoing emergency laparotomy was determined

Methods

The Royal Melbourne Hospital (RMH) is a level 1 traumacentre that manages about 1800 emergency general surgi-cal patients and 900 patients with major trauma each year

The Department of General Surgical Specialties managesall acute trauma and EGS presentations to the hospital

A retrospective study of all consecutive emergency gen-eral surgical admissions between 1 February 2009 and 31

January 2013 was performed using extracted data from thehospital administrative database as well as the Department

of General Surgical Specialtiesrsquo database Two 2-year intervals before and after the introduction of the new model of care in February 2011 were analysed

The study population consisted of patients admitteddirectly from the emergency department in addition tothose transferred to general surgical units after initialadmission to other units Inpatient referrals were excluded

The study was approved by Melbourne Health Office forResearch

Previous emergency general surgery provision model

The previous model of emergency care at RMH requiredeach subspecialty general surgical unit (breastendocrinecolorectal upper gastrointestinalhepatobiliary transplant)to participate in a rotating 24-h emergency on-call roster

The unitrsquos registrar was responsible for both elective andemergency patients The surgeon was not required on siteand was consulted as required This model included theinterval from 1 February 2009 to 31 January 2011 in thepresent study

Establishment of a consultant-led acute surgicalunit

In February 2011 an acute surgical service was estab-lished as a consultant-led EGS service The EGS service

aims to prioritize and improve the care of patients throughearly and increased on-site consultant input The serviceaims to facilitate safe and efficient patient management from the emergency department ensure rational and judi-cious use of diagnostics reduce after-hours surgery andminimize the impact on elective surgery In addition theEGS service is designed to increase trainee supervision andeducation

The EGS model of care is led by a consultant on site indaytime hours (0700 to 1800 hours from Monday to Fri-day 0800 to 1300 hours at weekends) managing all acuteand existing EGS and trauma admissions and supervisingthe junior staff of the EGS and trauma teams The consul-

tants participate actively in handovers ward rounds patient assessment in the emergency department and attendingemergency theatre The EGS model functions without a dedicated EGS theatre or a dedicated admission ward

The service does not benefit from additional radiology services

National standards for emergency departments

The introduction of the EGS service at the RMH occurred1 year before the change from the lsquo8-h rulersquo to the NEATrsquo4-h rulersquo Establishment of the EGS service was a com-

ponent of the hospitalrsquos response to the requirement by 2015 for 90 per cent of all emergency patients to be admit-ted or discharged within 4 h of presentation to the emer-gency department 6 According to the National Health Per-formance Authority in Australia the baseline figure forpatients moving through emergency departments within4 h ranged from 55 to 71 per cent in 201222

Data collection

Retrieved information included patientsrsquo demographicdata (age sex ethnicity) and administrative data (admis-sion and discharge dates admission and discharge unitsemergency department and hospital length of stay) Clin-ical data included primary admission diagnosis majorco-morbidities surgical interventions and morbidity andmortality rates

De1047297nition of complications

Complications are recorded in the Department of GeneralSurgical Specialtiesrsquo prospective database and reviewed

copy 2015 BJS Society Ltd wwwbjscouk BJS 2015 102 1726ndash1732Published by John Wiley amp Sons Ltd



1728 R Shakerian B N Thomson A Gorelik I P Hayes and A R Skandarajah

on a weekly basis at the departmentrsquos morbidity andmortality audit Each complication is captured as anlsquoepisodersquo in order to allow for more than one complicationto be recorded for each patient where it is indicated The

weekly peer review of complications results in grading of

each episode according to the ClavienndashDindo classifica-tion (IndashV) of surgical complications23 A further monthly subaudit committee reviews and finalizes the capturedcomplications

In this study complications following elective proce-dures requiring acute readmission and those secondary to endoscopic and radiological interventions performed by non-general surgical units were excluded

The complication rate was determined for all emergency general surgical admissions and subsequently for patientsmanaged exclusively by the general surgical units and theEGS service (excluding transfers) as well as for patients

undergoing emergency laparotomy Mortality was definedas in-hospital complication-related death

Statistical analysis

A comparison of outcomes between the two time periods was performed Differences in patientsrsquo baseline charac-teristics and outcomes between the two time frames wereassessed using theχ2 test for categorical data and either Stu-dentrsquos t test or the Wilcoxon rank sum test for continuousdata Administrative and clinical outcomes were assessedusing multivariable regression analysis with adjustment forbaseline differences between the two groups All analyses

were performed using Statareg 12 (StataCorp LP CollegeStation Texas USA) P lt 0sdot050 was considered statistically significant

Results

The study population included a total of 7233 emergency general surgical admissions (Table 1) Hospital performanceagainst the NEAT target was found to improve from 68sdot2per cent in 2011ndash2012 to 70sdot9 per cent in 2012ndash2013

Number of admissions and operations

The increase in acute admissions in the EGS period wasmatched by a 41sdot0 per cent increase in the total numberof emergency operations performed by the service from1279 to 1804 (Table 2) The three most frequent admissiondiagnoses in both intervals were acute appendicitis biliary disease and non-specific abdominal pain (Table 1) A total of 540 emergency non-trauma laparotomies were performedin the study period (Table 2)

Table 1 Study population characteristics and admission diagnoses

in emergency general surgery

Pre-EGS

( n=2765)

EGS

( n=4468) Pdagger

Mean age (years) 51sdot6 50sdot2 0sdot006Dagger

Sex 0sdot071

Male 1352 (48sdot9) 2087 (46sdot7)

Female 1413 (51sdot1) 2381 (53sdot3)

Co-morbidities

Hypertension 231 (8sdot4) 221 (4sdot9) lt 0sdot001

Dyslipidaemia 73 (2sdot6) 12 (0sdot3) lt 0sdot001

COPD 26 (0sdot9) 44 (1sdot0) 0sdot828

Diabetes 94 (3sdot4) 257 (5sdot8) lt 0sdot001

IHD 37 (1sdot3) 52 (1sdot2) 0sdot536

Atrial 1047297brillation 90 (3sdot3) 116 (2sdot6) 0sdot113

Renal impairment 104 (3sdot8) 109 (2sdot4) 0sdot001

Admission diagnosis

Non-speci1047297c abdominal pain 227 (8sdot2) 561 (12sdot6)

Acute appendicitis 369 (13sdot3) 532 (11sdot9)

Biliary disease 308 (11sdot1) 36 1 (8sdot1)

Perianalpilonidal abscess 145 (5sdot2) 219 (4sdot9)

Acute pancreatitis 211 (7sdot6) 209 (4

sdot7)

Diverticular diseasediverticulitis 147 (5sdot3) 192 (4sdot3)

Intestinal obstruction 227 (8sdot2) 179 (4sdot0)

Gastritiscolitisgastroenteritis 92 (3sdot3) 164 (3sdot7)

Skin and soft tissue infection 65 (2sdot4) 152 (3sdot4)

G astrointestinal bleed 100 (3sdot6) 127 (2sdot8)

Gynaecological 54 (2sdot0) 96 (2sdot1)

Hernia 105 (3sdot8) 85 (1sdot9)

Constipation 39 (1sdot4) 73 (1sdot6)

Urological 36 (1sdot3) 46 (1sdot0)

Other 640 (23sdot1) 1472 (32sdot9)

Values in parentheses are percentages Includes a spectrum of conditions with small admission numbers that have been grouped together EGSemergency general surgery service COPD chronic obstructivepulmonary disease IHD ischaemic heart disease daggerχ2 test except

DaggerStudentrsquos t test

Effects on length of stay

Establishment of the EGS service resulted in a signifi-cant reduction in both emergency department and hospitallengths of stay Duration of stay in the emergency depart-ment was reduced by 2sdot0h (from 8sdot0 (iqr 6ndash11) to 6sdot0(5ndash8)h P lt 0sdot001) The length of hospital stay was reducedby 1sdot0 day (from 3sdot0 (2ndash6) to 2sdot0 (1ndash4) days P lt 0sdot001)Improvements in length of stay remained significant afteradjustment for patientsrsquo age sex and co-morbidities withpatients in the EGS group having a 11 sdot3 (95 per cent

ci 5sdot6 to 17

sdot1) per cent reduction in hospital and a 21

sdot5

(18sdot5 to 24sdot5) per cent reduction in emergency department length of stay compared with the pre-EGS interval (both

P lt 0sdot001)

Complication frequency and severity

The incidence of complication episodes for all emergency admissions was reduced by 46sdot8 per cent from 172 (6sdot2 per





Table 2 Emergency general surgical procedures

Pre-EGS

( n=1279)

EGS

( n=1804)

Appendicectomy 368 (28sdot8) 536 (29sdot7)

Cholecystectomy 164 (12sdot8) 239 (13

sdot2)

Laparotomy 314 (24sdot6) 226 (12sdot5)

Adhesiolysisplusmn small bowel

resection

87 83

Colonic resection 75 45

Hartmann procedure 23 10

Exploratory laparotomy 44 24

Repair of gastricduodenal

perforationbleeding

27 14

Drainage of intra-abdominal

abscess

18 15

Other 40 35

Perianalpilonidal abscessanal

1047297stula

115 (9sdot0) 182 (10sdot1)

Wound debridementsoft tissue

abscess

85 (6sdot6) 152 (8sdot4)

Hernia repair 69 (5sdot4) 85 (4

sdot7)

Other 164 (12sdot8) 384 (21sdot3)

Values in parentheses are percentage of procedures Includes a spectrumof procedures with small numbers that have been grouped together EGSemergency general surgery service

cent) before to 147 (3sdot3 per cent) after establishment of theEGS service ( P lt 0sdot001) For patients managed exclusively by the general surgical units (pre-EGS 2765 EGS 3447)

there was a 56sdot5 per cent reduction in the incidence of complication episodes amongst the EGS cohort (from 6sdot2

to 2sdot

7 per cent P lt

0sdot

001) There was no difference in the incidence of grade IndashIIIcomplication episodes between the pre-EGS and EGScohorts However the proportion of grade IV and V com-

plications was reduced significantly from 27sdot9 to 15sdot0per cent ( P = 0sdot018) with the greatest reduction in grade

V complications (from 16sdot9 to 8 per cent P = 0sdot039) This remained significant after the adjustment for typeof surgery (laparotomy etc) co-morbidities and intensivecare unit (ICU) admission (grade IV and V complicationsodds ratio 0sdot38 95 per cent ci 0sdot16 to 0sdot93 P = 0sdot033)

The incidence of complication episodes in emergency patients managed by general surgical units before and afterthe establishment of the EGS service are summarized inTable 3

The incidence of complications in patients managed without surgery in the pre-EGS cohort was 1sdot3 per cent

(19 of 1486) compared with 1sdot0 per cent (16 of 1643)in the EGS cohort ( P = 0sdot430) For those managed surgi-cally the postoperative complication rate was 12sdot0 per cent (153 of 1279) and 4sdot3 per cent (77 of 1804) respectively ( P lt 0sdot001)

Table 3 Incidence of complication episodes in patients managed

by general surgical units before and after the establishment of

the emergency general surgery service

Cla vi en ndash Di nd o gra de Pre- EGS ( n=172) EGS ( n=93)

I 26 (15sdot1) 20 (22)

II 49 (28sdot5) 30 (32)

III 49 (28sdot5) 29 (31)

IV 19 (11sdot0) 7 (8)

V (death) 29 (16sdot9) 7 (8)

Non-operative 10 2

Postoperative 19 5

Values in parentheses are percentages EGS emergency general surgery service

The complication rate following emergency laparotomy was reduced from 24sdot8 per cent (78 of 314) in the pre-EGSinterval to 19sdot0 per cent (43 of 226) in the EGS inter-

val ( P = 0sdot111) The laparotomy-related mortality rate was

significantly reduced in the EGS cohort from 23 per cent (18 of 78) to 12 per cent (5 of 43) ( P lt 0sdot001)

Specific complications are shown in Table S1 (supportinginformation)

Intensive care unit admissions

The proportion of complication episodes leading to ICU admission decreased from 11sdot0 per cent (19 of 172) in thepre-EGS interval to 8 per cent (7 of 93) in the EGS periodthis difference was not significant ( P = 0sdot360)

Mortality

There was a significant reduction in the number of deathsfrom 29 (16sdot9 per cent) of 172 in the pre-EGS period toseven (8 per cent) of 93 in the EGS period ( P = 0sdot039) Inthe pre-EGS interval 18 of the postoperative deaths werefollowing emergency laparotomy and one occurred after adiagnostic laparoscopy In the EGS interval all five postop-erative deaths were following laparotomy (cardiovascular3 ischaemic gut 1 omental patch leak 1) Although admis-sion diagnoses were known for all patients who died thespecific cause of death was documented only for the EGScohort No further additional information (apart fromdeath) was documented in the pre-EGS database Post-operative and non-operative deaths are summarized inTable S2 (supporting information)

Discussion

Despite the significant increase in workload of emergency surgery reduced emergency department and hospi-tal lengths of stay were achieved in conjunction with





reduced complication rates following the establishment of a consultant-led EGS service The most commonadmission diagnoses re1047298ected the disease spectrum withinEGS reported by others132425 The most commonly per-formed operations also re1047298ected the experience of other

emergency surgery units1425 ndash28 In the present study areduction in the number of patients admitted with intesti-nal obstruction was noted to correlate with a reduction inthe number of emergency laparotomies being performedin the EGS interval

This study found an increase in admissions for acuteappendicitis biliary disease perianalpilonidal diseasediverticular disease and skin and soft tissue infections dur-ing the EGS period The increase in acute admissions hasbeen well described in both population-based studies5 andthose looking at specific management of acute appendicitis

and acute cholecystitis in the EGS setting101720212930

The number of patients admitted and subsequently dis-charged with a diagnosis of non-specific abdominal painmore than doubled following establishment of the acuteservice As the EGS service aims to facilitate 1047298ow throughthe emergency department patients with undifferentiatedor non-specific abdominal pain are routinely referred tothe service accounting for the increase in admissions withthis diagnosis Non-specific abdominal pain defined as

acute abdominal pain of less than 7 daysrsquo duration whereno diagnosis is reached after assessment and investigationaccounts for 13ndash40 per cent of all surgical admissions withabdominal pain in the UK 31 Abdominal pain is increas-

ingly being managed by acute surgical units owing to thetime restraints imposed on emergency departments Simi-larly owing to their presentation with abdominal pain as aprimary complaint patients with gynaecological urolog-ical and gastrointestinal conditions are also increasingly

being referred to the EGS services A significant decrease in the duration of hospital stay

was demonstrated in the present study re1047298ecting theexperience of others111316 Although EGS services haveled to earlier surgical assessment in the emergency department 12131719 this study also found a reductionin emergency department length of stay

A number of studies332 ndash35 have demonstrated trendstowards emergency patients being older with higher acuity and multiple co-morbidities and experiencing adverse

outcomes compared with the elective surgery populationPatients with emergency surgical conditions do not benefit from preoperative care and optimization to the same extent as patients undergoing high-risk elective operations withmany of the predictors of perioperative morbidity not being modifiable owing either to their nature (age sex)or to the time constraints of the emergency condition

(for example perforated organ requiring immediatesurgery)36

This study showed a significant reduction in complica-tion episodes both in the overall patient population and inpatients managed exclusively by the general surgical units

The overall morbidity rate of 3sdot3 per cent in the

EGS patient cohort is well below the 12ndash24sdot7 percent rate reported in the literature for the EGSpopulation1132333738 The overall mortality rate of 8per cent is within the reported range of 1sdot4ndash15sdot6 percent 311323337 For patients undergoing emergency laparo-tomy the overall morbidity and mortality rates in theEGS cohort were 19sdot0 and 12 per cent respectively Theoverall mortality rate in patients having emergency laparo-tomy has been reported to be approximately 14ndash15 percent 34353940

ClavienndashDindo grades IndashIII are often under-reported

compared with grade IVndashV complications4142

At RMHthe surgical audit database was upgraded to coincide withthe introduction of the EGS service A shift to a real-timeelectronic database has enabled accurate and up-to-datedata capture in particular relating to complication episodesand to facilitating the hand-over process It is possible that the increased consultant involvement in patient manage-ment has improved recognition and capture of compli-cation data as demonstrated by the increased number of grade Indash III complications in the EGS cohort although thistrend was not statistically significant

Although this was a retrospective study the prospectivedatabases were designed to facilitate data capture and anal-

ysis A further limitation of the study was the exclusion of patients who were transferred from the EGS service to thesubspecialty general surgical units This exclusion was nec-essary as their surgical care provision had changed fromthe consultant-led model back to the traditional model Inaddition although the impact of the NEAT on durationof stay in the emergency department needs to be acknowl-edged when assessing the performance of the EGS serviceit is important to note that there was minimal change inthe 4-h admission rate during the study period Thus theauthors believe the observed improvements are unlikely tobe due to the NEAT or other changes occurring as part of

the implementation of the 4-h rule

Disclosure

The authors declare no con1047298ict of interest

References

1 Stewart B Khanduri P McCord C Ohene-Yeboah M

Uranues S Rivera FV et al Global disease burden of





conditions requiring emergency surgery Br J Surg 2014

101 e9ndash e22

2 Bergenfelz A Soslashreide K Improving outcomes in emergency

surgery Br J Surg 2014 101 e1ndashe2

3 Symons NRA Moorthy K Almoudaris AM Bottle A Aylin

P Vincent CA et al Mortality in high-risk emergency general surgical admissions Br J Surg 2013 100

1318ndash1325

4 Poole GH Glyn T Srinivasa S Hill AG Modular acute

system for general surgery hand over the operation not the

patient ANZ J Surg 2012 82 156ndash160

5 Gale SC Shafi S Dombrovskiy VY Arumugam D Crystal

JS The public health burden of emergency general surgery

in the United States J Trauma Acute Care Surg 2014 77

202ndash208

6 Perera ML Davies AW Gnaneswaran N Giles M Liew D

Ritchie P et al Clearing emergency departments and

clogging wards National Emergency Access Target and the

law of unintended consequences Emerg Med Australas 2014

26 549ndash555

7 Leppaumlniemi A Organization of emergency surgery Br J

Surg 2014 101 e7ndashe8

8 Eijsvoogel CFH Peters RW Budding AJ Ubbink DT

Vermeulen H Schep NWL Implementation of an acute

surgical admission ward Br J Surg 2014 101 1434ndash 1438

9 Leppaumlniemi A Jousela I A traffic-light coding system to

organize emergency surgery across surgical disciplines Br J

Surg 2014 101 e134ndash e140

10 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 2014 101

e141ndashe146

11 OrsquoMara MS Scherer L Wisner D Owens LJ Sustainability and success of the acute care surgery model in the

nontrauma setting J Am Coll Surg 2014 219 90ndash98

12 Qureshi A Smith A Wright F Brenneman F Rizoli S

Hsieh T et al The impact of an acute care emergency

surgical service on timely surgical decision-making and

emergency department overcrowding J Am Coll Surg 2011

213 284ndash 293

13 Von Conrady D Hamza S Weber D Kalani K Epari K

Wallace M et al The acute surgical unit improving

emergency care ANZ J Surg 2010 80 933ndash936

14 Britt RC Weireter LJ Britt LD Initial implementation of

an acute care surgery model implications for timeliness of

care J Am Coll Surg 2009 209 421ndash42415 Parasyn AD Truskett PG Bennett M Lum S Barry J

Haghighi K et al Acute-care surgical service a change in

culture ANZ J Surg 2008 79 12ndash18

16 Sorelli PG El-Masry NS Dawson PM Theodorou NA

The dedicated emergency surgeon towards

consultant-based acute surgical admissions Ann R Coll Surg

Engl 2008 90 104ndash108

17 Lancashire JF Steele M Parker D Puhalla H Introduction

of an acute surgical unit comparison of performance

indicators and outcomes for operative management of acute

appendicitis World J Surg 2014 38 1947ndash 1953

18 Brockman SF Scott S Guest GD Stupart DA Ryan S

Watters DAK Does an acute surgical model increase the

rate of negative appendicectomy or perforated appendicitis

ANZ J Surg 2013 83 744ndash74719 Cubas RF Goacutemez NR Rodriguez S Wanis M Sivanandam

A Garberoglio CA Outcomes in the management of

appendicitis and cholecystitis in the setting of a new acute

care surgery service model impact on timing and cost J Am

Coll Surg 2012 215 715ndash721

20 Pepingco L Eslick GD Cox MR The acute surgical unit as

a novel model of care for patients presenting with acute

cholecystitis Med J Aust 2012 196 509ndash510

21 Britt RC Bouchard C Weireter LJ Britt LD Impact of

acute care surgery on biliary disease J Am Coll Surg 2010

210 595ndash601

22 Commonwealth Scientific and Industrial Research

Organisation (CSIRO) Evidence Driven Strategies for Meeting Hospital Performance Targets 2013

httpspublicationscsiroau [accessed 21 June 2015]

23 Dindo D Demartines N Clavien P-A Classification of

surgical complications a new proposal with evaluation in a

cohort of 6336 patients and results of a survey Ann Surg

2004 240 205ndash 213

24 Hameed SM Brenneman FD Ball CG Pagliarello J Razek

T Parry N et al General surgery 2sdot0 the emergence of

acute care surgery in Canada Can J Surg 2010 53 79ndash83

25 Cox MR Cook L Dobson J Lambrakis P Ganesh S

Cregan P Acute surgical unit a new model of care ANZ J

Surg 2010 80 419ndash424

26 Hsee L Devaud M Middelberg L Jones W Civil I Acutesurgical unit at Auckland City Hospital a descriptive

analysis ANZ J Surg 2012 82 588ndash591

27 Matsushima K Cook A Tollack L Shafi S Frankel H An

acute care surgery model provides safe and timely care for

both trauma and emergency general surgery patients J Surg

Res 2011 166 e143ndashe147

28 Ahmed HM Gale SC Tinti MS Shiroff AM Macias AC

Rhodes SC et al Creation of an emergency surgery service

concentrates resident training in general surgical

procedures J Trauma Acute Care Surg 2012 73 599ndash604

29 Pillai S Hsee L Pun A Mathur S Civil I Comparison of

appendicectomy outcomes acute surgical versus traditional

pathway ANZ J Surg 2013 83 739ndash74330 Lehane CW Jootun RN Bennett M Wong S Truskett P

Does an acute care surgical model improve the management

and outcome of acute cholecystitis ANZ J Surg 2010 80

438ndash442

31 Association of Surgeons of Great Britain and Ireland

(ASGBI) Commissioning Guide 2014 Emergency General

Surgery (Acute Abdominal Pain) wwwasgbiorguken

publicationssurgical_resources_and_documentscfm

[accessed 21 June 2015]





32 Akinbami F Askari R Steinberg J Panizales M Rogers SO

Factors affecting morbidity in emergency general surgery

Am J Surg 2011 201 456ndash462

33 Ingraham AM Cohen ME Raval MV Ko CY Nathens AB

Comparison of hospital performance in emergency versus

elective general surgery operations at 198 hospitals J AmColl Surg 2011 212 20ndash28e21

34 Al-Temimi MH Griffee M Enniss TM Preston R Vargo

D Overton S et al When is death inevitable after emergency

laparotomy Analysis of the American College of Surgeons

National Surgical Quality Improvement Program database

J Am Coll Surg 2012 215 503ndash511

35 Saunders DI Murray D Pichel AC Varley S Peden CJ

Variations in mortality after emergency laparotomy the first

report of the UK Emergency Laparotomy Network Br J

Anaesth 2012 109 368ndash375

36 Peden CJ Emergency surgery in the elderly patient

a quality improvement approach Anaesthesia 2011 66

440ndash445


Effect of trauma center status on 30-day outcomes after

emergency general surgery J Am Coll Surg 2011 212

277ndash286

38 Ingraham AM Haas B Cohen ME Ko CY Nathens AB

Comparison of hospital performance in trauma vs emergency and elective general surgery implications for

acute care surgery quality improvement Arch Surg 2012

147 591ndash598

39 Barrow E Anderson ID Varley S Pichel AC Peden CJ

Saunders DI et al Current UK practice in emergency

laparotomy Ann R Coll Surg Engl 2013 95 599ndash603

40 Huddart S Peden CJ Swart M McCormick B

Dickinson M Mohammed MA et al Use of a pathway

quality improvement care bundle to reduce mortality

after emergency laparotomy Br J Surg 2015 102

57ndash66

41 Dindo D Hahnloser D Clavien P-A Quality assessment

in surgery riding a lame horse Ann Surg 2010 251

766ndash771

42 Gunnarsson U Seligsohn E Jestin P Paringhlman L

Registration and validity of surgical complicationsin colorectal cancer surgery Br J Surg 2003 90

454ndash459

Supporting information

Additional supporting information may be found in the online version of this article

Table S1 Summary of complication types according to ClavienndashDindo classification of surgical complications (Worddocument)

Table S2 Summary of mortality (Word document)





studies7ndash 16 have evaluated the impact of new models of EGS care on patient outcomes Owing to their prevalenceas common emergency conditions acute appendicitis andbiliary disease have been the focus of most studies compar-ing traditional models of care with the new models 1017 ndash21

The impact on administrative and clinical outcomeshas been assessed predominantly in the context of thesetwo conditions with only a few studies analysing theimpact on the entire cohort of emergency general surgicaladmissions

The aim of the present study was to determine the impact of an EGS service on the management of all emergency general surgical patients Outcomes such as emergency department and hospital length of stay as well as theoverall rate of complications were included In additionthe complication rate for patients undergoing emergency laparotomy was determined

Methods

The Royal Melbourne Hospital (RMH) is a level 1 traumacentre that manages about 1800 emergency general surgi-cal patients and 900 patients with major trauma each year

The Department of General Surgical Specialties managesall acute trauma and EGS presentations to the hospital

A retrospective study of all consecutive emergency gen-eral surgical admissions between 1 February 2009 and 31

January 2013 was performed using extracted data from thehospital administrative database as well as the Department

of General Surgical Specialtiesrsquo database Two 2-year intervals before and after the introduction of the new model of care in February 2011 were analysed

The study population consisted of patients admitteddirectly from the emergency department in addition tothose transferred to general surgical units after initialadmission to other units Inpatient referrals were excluded

The study was approved by Melbourne Health Office forResearch

Previous emergency general surgery provision model

The previous model of emergency care at RMH requiredeach subspecialty general surgical unit (breastendocrinecolorectal upper gastrointestinalhepatobiliary transplant)to participate in a rotating 24-h emergency on-call roster

The unitrsquos registrar was responsible for both elective andemergency patients The surgeon was not required on siteand was consulted as required This model included theinterval from 1 February 2009 to 31 January 2011 in thepresent study

Establishment of a consultant-led acute surgicalunit

In February 2011 an acute surgical service was estab-lished as a consultant-led EGS service The EGS service

aims to prioritize and improve the care of patients throughearly and increased on-site consultant input The serviceaims to facilitate safe and efficient patient management from the emergency department ensure rational and judi-cious use of diagnostics reduce after-hours surgery andminimize the impact on elective surgery In addition theEGS service is designed to increase trainee supervision andeducation

The EGS model of care is led by a consultant on site indaytime hours (0700 to 1800 hours from Monday to Fri-day 0800 to 1300 hours at weekends) managing all acuteand existing EGS and trauma admissions and supervisingthe junior staff of the EGS and trauma teams The consul-

tants participate actively in handovers ward rounds patient assessment in the emergency department and attendingemergency theatre The EGS model functions without a dedicated EGS theatre or a dedicated admission ward

The service does not benefit from additional radiology services

National standards for emergency departments

The introduction of the EGS service at the RMH occurred1 year before the change from the lsquo8-h rulersquo to the NEATrsquo4-h rulersquo Establishment of the EGS service was a com-

ponent of the hospitalrsquos response to the requirement by 2015 for 90 per cent of all emergency patients to be admit-ted or discharged within 4 h of presentation to the emer-gency department 6 According to the National Health Per-formance Authority in Australia the baseline figure forpatients moving through emergency departments within4 h ranged from 55 to 71 per cent in 201222

Data collection

Retrieved information included patientsrsquo demographicdata (age sex ethnicity) and administrative data (admis-sion and discharge dates admission and discharge unitsemergency department and hospital length of stay) Clin-ical data included primary admission diagnosis majorco-morbidities surgical interventions and morbidity andmortality rates

De1047297nition of complications

Complications are recorded in the Department of GeneralSurgical Specialtiesrsquo prospective database and reviewed














Results






Pre-EGS

( n=2765)

EGS

( n=4468) Pdagger


Sex 0sdot071

Male 1352 (48sdot9) 2087 (46sdot7)

Female 1413 (51sdot1) 2381 (53sdot3)

Co-morbidities








Admission diagnosis






sdot7)










Other 640 (23sdot1) 1472 (32sdot9)





ci 5sdot6 to 17


sdot5


P lt 0sdot001)








Pre-EGS

( n=1279)

EGS

( n=1804)



sdot2)



resection

87 83





perforationbleeding

27 14


abscess

18 15

Other 40 35


1047297stula

115 (9sdot0) 182 (10sdot1)


abscess

85 (6sdot6) 152 (8sdot4)


sdot7)

Other 164 (12sdot8) 384 (21sdot3)




to 2sdot

7 per cent P lt

0sdot











I 26 (15sdot1) 20 (22)

II 49 (28sdot5) 30 (32)

III 49 (28sdot5) 29 (31)

IV 19 (11sdot0) 7 (8)

V (death) 29 (16sdot9) 7 (8)

Non-operative 10 2

Postoperative 19 5








Mortality


Discussion



























Disclosure


References








101 e9ndash e22





1318ndash1325







202ndash208





26 549ndash555








Surg 2014 101 e134ndash e140




e141ndashe146







213 284ndash 293












Engl 2008 90 104ndash108


















210 595ndash601







2004 240 205ndash 213






Surg 2010 80 419ndash424






Res 2011 166 e143ndashe147










438ndash442



























440ndash445




277ndash286




147 591ndash598








57ndash66



766ndash771



454ndash459


















Results






Pre-EGS

( n=2765)

EGS

( n=4468) Pdagger


Sex 0sdot071

Male 1352 (48sdot9) 2087 (46sdot7)

Female 1413 (51sdot1) 2381 (53sdot3)

Co-morbidities








Admission diagnosis






sdot7)










Other 640 (23sdot1) 1472 (32sdot9)





ci 5sdot6 to 17


sdot5


P lt 0sdot001)








Pre-EGS

( n=1279)

EGS

( n=1804)



sdot2)



resection

87 83





perforationbleeding

27 14


abscess

18 15

Other 40 35


1047297stula

115 (9sdot0) 182 (10sdot1)


abscess

85 (6sdot6) 152 (8sdot4)


sdot7)

Other 164 (12sdot8) 384 (21sdot3)




to 2sdot

7 per cent P lt

0sdot











I 26 (15sdot1) 20 (22)

II 49 (28sdot5) 30 (32)

III 49 (28sdot5) 29 (31)

IV 19 (11sdot0) 7 (8)

V (death) 29 (16sdot9) 7 (8)

Non-operative 10 2

Postoperative 19 5








Mortality


Discussion



























Disclosure


References








101 e9ndash e22





1318ndash1325







202ndash208





26 549ndash555








Surg 2014 101 e134ndash e140




e141ndashe146







213 284ndash 293












Engl 2008 90 104ndash108


















210 595ndash601







2004 240 205ndash 213






Surg 2010 80 419ndash424






Res 2011 166 e143ndashe147










438ndash442



























440ndash445




277ndash286




147 591ndash598








57ndash66



766ndash771



454ndash459










Pre-EGS

( n=1279)

EGS

( n=1804)



sdot2)



resection

87 83





perforationbleeding

27 14


abscess

18 15

Other 40 35


1047297stula

115 (9sdot0) 182 (10sdot1)


abscess

85 (6sdot6) 152 (8sdot4)


sdot7)

Other 164 (12sdot8) 384 (21sdot3)




to 2sdot

7 per cent P lt

0sdot











I 26 (15sdot1) 20 (22)

II 49 (28sdot5) 30 (32)

III 49 (28sdot5) 29 (31)

IV 19 (11sdot0) 7 (8)

V (death) 29 (16sdot9) 7 (8)

Non-operative 10 2

Postoperative 19 5








Mortality


Discussion



























Disclosure


References








101 e9ndash e22





1318ndash1325







202ndash208





26 549ndash555








Surg 2014 101 e134ndash e140




e141ndashe146







213 284ndash 293












Engl 2008 90 104ndash108


















210 595ndash601







2004 240 205ndash 213






Surg 2010 80 419ndash424






Res 2011 166 e143ndashe147










438ndash442



























440ndash445




277ndash286




147 591ndash598








57ndash66



766ndash771



454ndash459






























Disclosure


References








101 e9ndash e22





1318ndash1325







202ndash208





26 549ndash555








Surg 2014 101 e134ndash e140




e141ndashe146







213 284ndash 293












Engl 2008 90 104ndash108


















210 595ndash601







2004 240 205ndash 213






Surg 2010 80 419ndash424






Res 2011 166 e143ndashe147










438ndash442



























440ndash445




277ndash286




147 591ndash598








57ndash66



766ndash771



454ndash459










101 e9ndash e22





1318ndash1325







202ndash208





26 549ndash555








Surg 2014 101 e134ndash e140




e141ndashe146







213 284ndash 293












Engl 2008 90 104ndash108


















210 595ndash601







2004 240 205ndash 213






Surg 2010 80 419ndash424






Res 2011 166 e143ndashe147










438ndash442



























440ndash445




277ndash286




147 591ndash598








57ndash66



766ndash771



454ndash459


























440ndash445




277ndash286




147 591ndash598








57ndash66



766ndash771



454ndash459






outcomes in emergency general surgery following the introduction of a consultant-led unit

Documents