Acute Surgical Unit Research Articles

Establishing a successful perioperative geriatric service in an Australian acute surgical unit.

The purpose of this study was to assess the impact of a perioperative geriatric service (PGS) in an acute surgical unit (ASU) on patient and organizational outcomes. Single centre retrospective cohort study. Inclusion criteria were patients over the age of 65 admitted to the ASU between January and June 2014 (pre-PGS) and 2015 (post-PGS). Chart reviews were performed to identify outcomes of interest including in-hospital morbidity and mortality, length of stay (LOS), 30-day representation and mortality. Geriatric admissions increased by 32% over the two study periods (154 pre-PGS and 203 post-PGS). Surgical intervention increased by 11% (P = 0.01). Significantly more medical complications (14% versus 33%, P < 0.001) were identified after the implementation of the PGS. Recognition of delirium in the over 80s also increased by 57%. Rate of surgical complications was unchanged over the study (28% pre-PGS and 34% post-PGS, P = 0.6). In-hospital (<1%, P = 0.5) and 30-day mortality (<1%, P = 0.6) remained low, as did 30-day representation (10% versus 8%, P = 0.5). A trend towards decreased LOS of 1 day was identified after the implementation of the PGS (P = 0.07). This study demonstrated successful implementation of a PGS into an ASU. This multi-disciplinary approach has been effective in maintaining low numbers of surgical complications, in-hospital mortality, LOS and patient representations despite an increased number of medical complications. This likely reflects more timely recognition and intervention of medically unwell patients with the PGS.

AB177. 101. Venous thromboembolic (VTE) prophylaxis

Background: Venous thromboembolic (VTE) disease is a common complication of hospitalised patients. VTE prophylaxis (VTEP) is considered a quality measure in surgical care, there has been little amount of evidence from Irish practice. VTE contributes significantly to length of hospital stay, morbidity and mortality. VTEP has led to decrease incidence of DVT and PE amongst hospitalised patients. The objective of this study is to demonstrate the compliance of our acute surgical unit to NICE guidelines in thromboprophylaxis of hospitalised patients.

How good are doctors at introducing themselves? #hellomynameis

BackgroundThis explorative study was triggered by the ‘#hellomynameis’ campaign initiated by Dr Kate Granger in the UK. Our objectives were twofold: first, to measure rates of introduction in an Irish...

Educating the workforce: improving the education and competencies of healthcare assistants in an acute surgical unit

It is widely recognised that healthcare assistants (HCAs) have taken some registered nurse (RN) roles; however, the importance of competencies, supervision and monitoring of HCAs is not always recognised. The aim of this project was to examine the education needs of HCAs for the tasks delegated to them and to provide an education day relevant to these needs. Methodology involved an audit of knowledge of the participating HCAs. The audit included a short questionnaire, participant observation and focus groups and it provided information on the needs of HCAs. Findings showed that HCAs spent 80% of their time on direct patient care, 5% on cleaning tasks and 15% on documentation. However, no direction was given to them and there was no monitoring from the RNs. Initially, one day of training was planned, but after feedback, two days were offered to maximise learning (see Box 2 ). After the sessions, attendees were given an evaluation form and the feedback from the two-day course was positive.

Emergency laparotomy outcomes before and after the introduction of an acute surgical unit

IntroductionEmergency laparotomy is associated with significant morbidity and mortality. This study compared emergency laparotomy outcomes in a traditional service to those after the introduction of an Acute Surgical Unit (ASU). MethodsA retrospective cohort study was performed by reviewing the medical records of all individuals that had an emergency laparotomy in twelve-month periods before and after the introduction of an ASU. Outcomes included time to surgical review, operation duration, length of stay, complications and mortality. Morbidity and mortality were compared to that predicted by P-Possum scores. ResultsIn the pre-ASU group there were 58 participants (26 males, 32 females) with a median age of 60 years (range 15–87) and median P-Possum predicted morbidity and mortality of 68% (18–98%) and 6% (1–66%) respectively. In the post-ASU group there were 109 participants (58 males, 53 females) with a median age of 63 years (range 11–100), and median P-Possum predicted morbidity and mortality of 82% (18–100%) and 12% (1–99%).Operating time decreased post-ASU (median 1 hr 31 min pre vs 1 hr 15 min post p = 0.030) and there was a reduction in the incidence of post-operative fistula formation (5% vs 0% p = 0.017). There were no other significant differences in morbidity or mortality. ConclusionsThe post-ASU cohort had shorter operative duration and reduced incidence of complicating fistulas but no other significant difference in outcomes. Further studies may define the impact of an ASU on clinical decision making, service delivery, morbidity and mortality in patients that undergo emergency laparotomy.

Provision of acute and elective general surgical care at a tertiary facility in the era of subspecialisation.

The need for an acute care and general surgical unit (ACGSU) to provide care for patients previously managed on an ad hoc basis by subspecialist units was recognised by the provincial government of the Western Cape Province, South Africa, the management of Groote Schuur Hospital (GSH) and the Department of Surgery. To describe the resulting ACGSU and its functioning. Data available from administrative records, patient files and operating room forms were collected in spreadsheet form for the period July 2013 - November 2016 inclusive. The ACGSU comprised a medical care team of four consultants and four to five trainees. A total of 7 571 patients were seen during the study period, the majority (66.1%) referred from the GSH Emergency Centre. Skin and soft-tissue infections formed the major disease complex. A total of 3 144 operative records were available. The most common procedures were wound debridement and inguinal hernia repairs. Trainees acted as primary surgeon in most cases. Complications (Clavien-Dindo grades I - V) were noted in 25.0% of patients. The ACGSU provides patient management that would otherwise complicate care in the subspecialist surgical units. It serves as a training ground for registrars and stands as a model for other institutions. Further research into the effect on patient care is planned.

Clinical Decision-Making: Observing the Smartphone User An Observational Study in Predicting Acute Surgical Patients' Suitability for Discharge.

An accurate and rapid assessment of an acutely unwell patient's clinical status is paramount for the physician. There is an increasing trend to rely on investigations and results to inform a clinician of a patient's clinical status, with the subtleties of clinical observation often ignored. The aim of this study was to determine if a patient's use of a smartphone during the initial clinical assessment by a surgical consultant could be used as a surrogate marker for patient well-being, represented as their suitability for sameday discharge. This was a prospective observational study performed over 2 periods at a tertiary hospital in South Australia. All patients admitted by junior surgical doctors from the emergency department to the acute surgical unit were eligible for inclusion. Upon consultant review, their status as a smartphone user was recorded in addition to their duration of hospital stay and basic demographic data. All patients and all but 1 of the consultants were blinded to the trial. Two hundred and twenty-one patients were eligible for inclusion. Of these patients, 11.3% were observed to be using a smartphone and 23.5% of patients were discharged home on day 1. Those who were observed to be using a smartphone were 5.29 times more likely to be discharged home on day 1 and were less likely to be subsequently readmitted. The addition of the smartphone sign to a surgeon's clinical acumen can provide yet another tool in aiding the decision for suitability for discharge.

Impact of an acute surgical unit on patient outcomes in South Australia

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. 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. 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. 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.

The Established Acute Surgical Unit: A reduction in nighttime appendicectomy without increased morbidity

IntroductionNighttime surgery for non-life threatening disease has been associated with poorer outcomes, but delaying surgery for acute appendicitis may also be detrimental. The aim was to assess the effect of the Acute Surgical Unit [ASU] model on nighttime surgery rates and outcomes for patients undergoing appendicectomy. MethodA retrospective review of medical records of patients having an appendicectomy. Primary outcomes were nighttime surgery rate, time from presentation to surgery, perforation rate, complication rate and length of stay. ResultsThere was a large increase in workload: Pre ASU 278, Early ASU 553 and Est. ASU 923. There was a significant decrease in nighttime surgery rates: Pre ASU 46.9%, Early ASU 30.2% and Established ASU 28.3% (Pre vs. Early p < 0.001; Pre vs. Est. p < 0.001; Early vs. Est p = 0.004). When comparing the Pre ASU and Established ASU groups there was an increase in mean time from presentation to surgery (Pre 14.43 Hrs, Est. 18.65 Hrs; p = 0.001), an increase in perforation rate that was not significant (Pre 9.8%, Est. 14.2%; p = 0.05) and similar complication rates (Pre 8.66%, Est. 7.04%; p = 0.37). There was a significant decrease in length of stay between the Early and Established ASU groups (Pre 3.1 D, Est. 2.8D, p = 0.01). At our institution there was no statistically significant increase in complications for patients undergoing nighttime appendicectomy (Night 10.0%, Day 8.2%; p = 0.16). ConclusionThere was a significant decrease in nighttime surgery, without any difference in morbidity or length of stay for patients treated within the Established ASU (compared to Pre ASU group). Level of evidenceIIb.

Subspecialty approach for the management of acute cholecystitis: an alternative to acute surgical unit model of care.

Acute cholecystitis is a common condition. Recent studies have shown an association between creation of an acute surgical unit (ASU) and improved outcomes. This study aimed to evaluate the outcomes of a subspecialty based approach to the management of acute cholecystitis as an alternative to the traditional 'generalist' general surgery approach or the ASU model. A 6-year retrospective analysis of outcomes in patients admitted under a dedicated upper gastrointestinal service for acute cholecystitis undergoing emergency laparoscopic cholecystectomy. Seven hundred emergency laparoscopic cholecystectomies were performed over this time. A total of 486 patients were available for analysis. The median time to operation was 2 days and median length of operation was 80 min. A total of 86.9% were performed during daylight hours. Eight cases were converted to open surgery (1.6%). Intra-operative cholangiography was performed in 408 patients. The major complication rate was 8.2%, including retained common bile duct stones (2.3%), sepsis (0.2%), post-operative bleeding (0.4%), readmission (0.6%), bile leak (2.1%), AMI (0.4%), unscheduled return to theatre (0.6%) and pneumonia (0.8%). There were no mortalities and no common bile duct injuries. Over a time period that encompasses the current publications on the ASU model, a subspecialty model of care has shown consistent results that exceed established benchmarks. Subspecialty management of complex elective pathologies has become the norm in general surgery and this study generates the hypothesis that subspecialty management of patients with complex emergency pathologies should be considered a valid alternative to ASU. Access block to emergency theatres delays treatment and prolongs hospital stay.

Ageing acute surgical population: the Auckland experience.

This study provides data supporting the supposition that more elderly patients are requiring surgical care and illustrates the risks associated with acute surgical illness in elderly patients. The clinical records database was accessed to identify all patients discharged from general surgery and acute surgical unit (ASU) during 2013 and 2014. These groups were stratified by age (over 80 years). Data were collected on number of patients discharged per year, length of stay, number of intensive care unit admissions and number of procedures and mortality rates. There is an increasing number of patients aged over 80 years who were discharged from ASU; 7.02% (n = 296) in 2013 and 8.20% (n = 344) in 2014. Patients aged over 80 years were spending 1.88 days (P-value < 0.001) longer in hospital than those under 80 years in 2014. Mortality rates in 2013 were 3.716 deaths per 100 admissions and 5.814 per 100 admissions in 2014. In 2013, the risk ratio of death in hospital for patients over 80 years was 36.4 (P-value < 0.001) times higher than patients under 80 years. The mean length of stay and mortality rates are higher for patients over 80 years. Mortality rates are higher in acute admissions compared with elective admissions. This identifies a need for increased care for elderly patients admitted for acute surgical care. We suggest a trial of attaching a specialist geriatrician to the ASU who will provide a service for at risk patients.

Ahead of the curve: Implementation of the first twenty-four hour Acute Surgical Assessment Unit (ASAU) in Ireland

Ahead of the curve: Implementation of the first twenty-four hour Acute Surgical Assessment Unit (ASAU) in Ireland

Is the acute surgical unit model feasible for Australian regional centres?

A significant proportion of general surgery emergency procedures are conducted after-hours in regional centres. The acute surgical unit (ASU) model reduces the number of after-hours operations performed. We review the burden of emergency surgery in a regional centre and assess what components of the ASU model would benefit regional hospitals. Retrospective analysis was performed on data for all emergency cases performed at Latrobe Regional Hospital (LRH) over a 1-year period. Time into and out of theatre was used to determine total theatre usage and if the operation occurred after-hours. ED triage time to theatre and start time for appendicectomy was compared to data from our metropolitan referral hospital, Monash Medical Centre (MMC), which has employed an ASU. General surgery emergency cases in regional areas are regular and predictable with a median of two emergency cases performed, and a mean theatre time of 156 min per day at LRH. On weekdays, 43.1% (n = 503) of emergency cases were done in the evening (18.00-24.00 hours), compared to 20.3% (n = 217) on weekends when an emergency theatre is available during the day. LRH performed more appendicectomies after-hours than MMC over a 1-year period. Regional centres have a significant burden of general surgery emergency procedures; of which the number performed after-hours is comparable to metropolitan centres. The number of procedures and theatre time required by these cases justify a dedicated emergency theatre in-hours similar to metropolitan ASU models and this would reduce emergency operating after-hours.

Frailty and cognitive impairment: Unique challenges in the older emergency surgical patient.

Older patients (>65 years of age) admitted as general surgical emergencies increasingly require improved recognition of their specific needs relative to younger patients. Two such needs are frailty and cognitive impairment. These are evolving research areas that the emergency surgeon increasingly requires knowledge of to improve short- and long-term patient outcomes. This paper reviews the evidence for frailty and cognitive impairment in the acute surgical setting by defining frailty and cognitive impairment, introducing methods of diagnosis, discussing the influence on prognosis and proposing strategies to improve older patient outcomes. Frailty is present in 25% of the older surgical population. Using frailty-scoring tools, frailty was associated with a significantly longer hospital stay and higher mortality at 30 and 90 days after admission to an acute surgical unit. Cognitive impairment is present in a high number of older acute surgical patients (approximately 70%), whilst acute onset cognitive impairment, termed delirium, is documented in 18%. However, patients with delirium had significantly longer hospital stays and higher in-hospital mortality than those with cognitive impairment. Improved knowledge of frailty and delirium by the emergency surgeon allows the specialised needs of older surgical patients to be taken into account. Early recognition, and consideration of minimally invasive surgery or radiological intervention alongside potentially transferable successful elective interventions such as comprehensive geriatric assessment, may help to improve short- and long-term patient outcomes in this vulnerable population.

ACUTE SURGICAL UNIT: THE CONSULTANT EXPERIENCE

Background Establishment of the Acute Surgical Unit (ASU) has redefined the approach to emergency surgery in Australia with quantitative data showing improvement in patient outcomes. However, as qualitative data regarding the ASU remains scarce, we sought to determine the impact of the ASU on overall surgeon job satisfaction. Aims The aim of this paper was to specifically address the impact of the ASU on consultant surgeons overall job satisfaction. Methods We designed a 34 – item questionnaire with consultant general surgeons addressing important aspects of the ASU. Themes included on – call rostering and workload, academic pursuits, surgical training, work – life balance and overall job satisfaction. Results We received responses from 88 surgeons currently working on ASU units, responding correctly and in full to the survey. Overall, our surveyed cohort reported better on – call rostering, improved surgical training and higher levels of job satisfaction and overall work – life balance with ASU implementation. Conclusion Preliminary qualitative results indicate that the ASU may improve on – call rostering, work – life balance and overall job satisfaction.

Acute surgical unit safely reduces unnecessary after-hours cholecystectomy.

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. 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. 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. 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.

Are mobile phones “The tick” with the infective bite: A microbial analysis of mobile devices within an acute surgical unit

Are mobile phones “The tick” with the infective bite: A microbial analysis of mobile devices within an acute surgical unit

Consultant cover on an acute surgical GP admission unit–driving down waiting times in a North-West hospital

Consultant cover on an acute surgical GP admission unit–driving down waiting times in a North-West hospital

Impact of introduction of an acute surgical unit on management and outcomes of small bowel obstruction.

The acute surgical unit (ASU) is a recently established model of care in Australasia and worldwide. Limited data are available regarding its effect on the management of small bowel obstruction. We compared the management of small bowel obstruction before and after introduction of ASU at a major tertiary referral centre. We hypothesized that introduction of ASU would correlate with improved patient outcomes. A retrospective review of prospectively maintained databases was performed over two separate 2-year periods, before and after the introduction of ASU. Data collected included demographics, co-morbidity status, use of water-soluble contrast agent and computed tomography. Outcome measures included surgical intervention, time to surgery, hospital length of stay, complications, 30-day readmissions, use of total parenteral nutrition, intensive care unit admissions and overall mortality. Total emergency admissions to the ASU increased from 2640 to 4575 between the two time periods. A total of 481 cases were identified (225 prior and 256 after introduction of ASU). Mortality decreased from 5.8% to 2.0% (P = 0.03), which remained significant after controlling for confounders with multivariate analysis (odds ratio = 0.24, 95% confidence interval 0.08-0.73, P = 0.012). The proportion of surgically managed patients increased (20.9% versus 32.0%, P = 0.003) and more operations were performed within 5 days from presentation (76.6% versus 91.5%, P = 0.02). Fewer patients received water-soluble contrast agent (27.1% versus 18.4%, P = 0.02), but more patients were investigated with a computed tomography (70.7% versus 79.7%, P = 0.02). The ASU model of care resulted in decreased mortality, shorter time to intervention and increased surgical management. Overall complications rate and length of stay did not change.

Changing models of care for emergency surgical and trauma patients in Singapore.

The last 15 years have seen changing patterns of injury in emergency surgery and trauma patients. The ability to diagnose, treat and manage these patients nonoperatively has led to a decline in interest in trauma surgery as a career. In addition, healthcare systems face multiple challenges, including limited resources, an ageing population and increasing subspecialisation of medical care, while maintaining government-directed standards and managing public expectations. In the West, these challenges have led to the emergence of a new subspecialty, 'acute care surgery', with some models of care providing dedicated acute surgical units or separating acute and elective streams with the existing manpower resources. The outcomes for emergency surgery patients and efficiency gains are promising. In Singapore, Khoo Teck Puat Hospital has implemented its first dedicated acute surgical unit. This article outlines the evolution of acute care surgery and its relevance to Asia.