Emergency Surgical Service Research Articles

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

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. 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. 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). 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.

Implementation of an acute care emergency surgical service: a cost analysis from the surgeon’s perspective

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. 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. 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). 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.

Consultant activity and the 2003 contract

The authors are correct in their statement that the 2003 contract awarded consultants more money for work they were already doing, because the Government ignored the available statistics. A major factor was missed. Over the same period, the Senior Registrar grade was abolished. In military terms, this was equivalent to the abolition of the sergeant's mess. At a stroke a cadre of newly qualified, up-to-date, highly motivated specialists was removed from the NHS. In many specialties, particularly surgical, inpatient care revolved round the SRs. Skilled scheduling, expert ward care, and the emergency surgical service were all hit without the provision of extra resources for the consultants to take these tasks over. As a result, ward care deteriorated, managers booked surgical admissions into impracticable lists, and consultants did the emergencies at the expense of the day job. This is the result of political manipulation of medical education to move from the highly qualified and experienced consultant to a “good enough” specialist who has to gain experience on the job. In the absence of adequate records for the crucial period, we will never know whether the loss of the SR grade was an important factor.

Incarcerated inguinal hernia and small bowel obstruction as a rare complication of a penile prosthesis

In this paper, we present a rare case of a small bowel obstruction secondary to an incarcerated inguinal hernia as a short-term complication of a penile prosthesis implantation. The patient underwent prosthesis implantation to treat refractory erectile dysfunction after a robotic-assisted laparoscopic radical prostatectomy. He presented 2 weeks later with the incarcerated hernia to our emergency department and surgical service. The hernia was repaired in a tension-free manner, and the bowel was uncompromised. The patient is symptom free at follow-up.

The Impact of an Acute Care Emergency Surgical Service on Timely Surgical Decision-Making and Emergency Department Overcrowding

This study evaluated how implementation of an acute care emergency surgery service (ACCESS) affected key determinants of emergency department (ED) length of stay, and particularly, surgical decision time. Also, we analyzed how ACCESS affected ED overcrowding. We conducted a before and after study of all ED patients referred to ACCESS from January 1, 2007 to June 30, 2009. ACCESS was implemented on July 1, 2008. The primary outcome was surgical decision time; the secondary outcome was a measure of overall ED overcrowding: "time-to-stretcher" for all ED patients. The control groups were patients referred to internal medicine or urology. Patients with appendicitis were studied in order to analyze the impact on patient outcomes and to determine barriers to efficient ED patient flow. Of 2,510 patients, 1,448 patients were pre-ACCESS, and 1,062 were after ACCESS implementation. Implementation of ACCESS was associated with a 15% reduction in surgical decision time (12.6 hours vs 10.8 hours, p < 0.01). During the same period, there were no significant changes in decision time for our control groups. Also, the mean time-to-stretcher for all ED patients decreased by 20%. In patients with appendicitis, we found that patient flow could be further improved by a timely request for surgical consultation and expedited imaging. Finally, we found that patients with nonperforated appendicitis with a fecalith on CT imaging were more likely to suffer perforation while waiting for surgery. ACCESS reduced surgical decision time for surgical patients. Also, ACCESS improved overall ED crowding, as measured by time-to-stretcher for ED patients. Further improvements could be made by improving time to imaging. Patients referred for nonperforated appendicitis with a fecalith on CT should have expedited surgery.

Evaluación y mejora del manejo del consentimiento informado en urgencias

To assess the preoperative management in our emergency surgical service and to improve the quality of the care provided to patients. In order to find the causes of non-compliance, the Ishikawa Fishbone diagram was used and eight assessment criteria were chosen. The first assessment includes 120 patients operated on from January to April 2007. Corrective measures were implemented, which consisted of meetings and conferences with doctors and nurses, insisting on the importance of the informed consent as a legal document which must be signed by patients, and the obligation of giving a copy to patients or relatives. The second assessment includes the period from July to October 2007 (n=120). We observed a high non-compliance of C1 signing of surgical consent (CRITERION 1: all patients or relatives have to sign the surgical informed consent for the operation to be performed [27.5%]) and C2 giving a copy of the surgical consent (CRITERION 2: all patients or relatives must have received a copy of the surgical informed consent for the Surgery to be performed [72.5%]) and C4 anaesthetic consent copy (CRITERION 4: all patients or relatives must have received a copy of the Anaesthesia informed consent corresponding to the operation performed [90%]). After implementing corrective measures a significant improvement was observed in the compliance of C2 and C4. In C1 there was an improvement without statistical significance. The carrying out of an improvement cycle enabled the main objective of this paper to be achieved: to improve the management of informed consent and the quality of the care and information provided to our patients.

Pulmonary vessel pseudo-aneurysm after blunt traumatic injury: A report of two cases

Pulmonaryarterypseudo-aneurysm(PAPA)resultingfromchesttrauma is uncommon. Seventeen cases have been described in theliterature [1–17]: 12 of these resulted from penetrating injuries[1,2,4,5,7,8,12,13,15–17], 4 from blunt injuries [3,9,11,14],and1case that involved penetrating chest trauma with simultaneouspulmonary artery and pulmonary vein pseudo-aneurysm [10].In 2006, Reade et al. first described the case of blunt traumaticmain PAPA, detected on initial computed tomography (CT) scan,that was treated non-operatively [14]. In every reported case, thetraumatic PAPA was repaired operatively by means of localresection (aneurysectomy), ligation of vessels, lobectomy orembolisation [5,15].The development and improvement of imaging techniques,especiallymultisliceCT scan,havepermittedthediagnosis of‘newinjuries’ in trauma patients. These injuries identified with moderndiagnostic technology may represent a challenge to the surgeon,who has to determine or characterise their nature and apply theappropriate management.Here,wereporttwocasesofpulmonaryvesselpseudo-aneurysmin blunt-trauma patients who were admitted to our emergencysurgical service (ESS) and were successful treated non-operatively.1. Case 1A 37-year-old man was involved in a collision with a car whileriding a bicycle and arrived at our ESS without any additionalinformation. The patient was not alert upon his admission to theemergency room. An orotracheal intubation was performed. Thechest physical examination showed multiple thoraco-abdominalexcoriations, and bilateral vesicular murmur was present withdiffuse bruises. The cardiocirculatory system was normal onphysical examination, and the focussed assessment with sono-graphy for trauma (FAST) showed fluid in hepatorenal and pelvicfields.Pelvicandrectalexaminationwasnormal,andtheurinewasclear. The Glasgow Coma Scale (GCS) score was 8 before sedation.Right tibia and fibula fractures (Gustilo grade IIIa) were observed.Acranial/thoracicCTscanshowedmultiplefacialfractures(nasal,maxillary, right zygomatic and bilateral orbital), as well as a smallright haemo-pneumothorax, a right PAPA measuring 24 mm 21mm 23mm (23-mm extension) and a right inferior pulmonaryvein pseudo-aneurysm measuring 10 mm (Fig. 1). An abdominal/pelvicCTshowedasmallrighthepaticlobelaceration,arightadrenalhaematomaand smallliquid collectionsinhepatic andpelvic fields.The patient underwent external fixation of tibia and fibulafractures performed by the orthopaedic surgery group. Facialfractures as well as the thoracic and abdominal lesions weremanaged non-operatively. The patient received care in the traumaintensive care unit (ICU), where he required continuous nora-drenalininfusionfor3days.Eightdaysafteradmission,thepatienthad internal fixation of tibia and fibula fractures. No specifictreatmentforthepseudo-aneurysmwasperformed.A repeatedCTscan performed 22 days after admission showed no evidence ofpseudo-aneurysm of pulmonary artery or vein. The patient’scondition improved rapidly, and the patient was discharged fromthe hospital 23 days after admission.2. Case 2A70-year-oldmanwasinvolvedinvehiclecrashwithapole.Theaccidentsiteassessmentrevealedthathewasnotwearingaseatbelt.Hislevelofconsciousnesswasunknown.Intheemergencyroom,hepresented with wheezing; chest examination showed paradoxicalmovementsoftherighthemithoraxwithinstabilityofchestwallandreducedhomolateralvesicularmurmurs.Orotrachealintubationandright chest drainage were performed. His heart rate was 74 beats/min,hisbloodpressurewas116/78 mmHgandhisheartsoundswerenormal on auscultation. His GCS score was 15 and no additionalinjurieswereobserved.TheFASTshowednofluidaccumulation.TheCTscanexaminationwithcontrastshowednosignofinjurytoheador

Improved Management of Acute Gallstone Disease After Regional Surgical Subspecialization

Acute gallstone disease is a common indication for emergency hospital admission, and evidence now strongly supports early laparoscopic cholecystectomy as the treatment of choice. Recent data from the UK suggest that this is achieved in a minority of cases with a high proportion of patients managed by deferred elective surgery or emergency open cholecystectomy. We present results of a policy of definitive treatment during index admission after subspecialist reorganization of a regional emergency surgical service. Data for all emergency gallstone admissions were retrieved from a prospectively collected regional surgical audit database and results were compared from 31 month periods before and after subspecialist service reorganization in August 2002. A total of 2442 patients were analyzed. Before subspecialization, 458 of 733 patients (62.4%) underwent cholecystectomy during index admission; after subspecialization, cholecystectomy during index admission for biliary colic/acute cholecystitis was achieved in 666 of 817 (81.5%) patients (90.2% laparoscopic, 6.5% conversion rate, and 3.3% primary open cholecystectomy) with a reduction in hospital stay from median 5 to 4 days. The rate of deferred surgery decreased from 37.5% to 18.4%. Early surgery reduced total hospital admission by more than 1 day per patient compared with deferred surgery. Early laparoscopic cholecystectomy during emergency admission is cost-effective and should be regarded as the standard of care. However, it requires appropriately trained surgeons and availability of a dedicated emergency room, which at present are not consistently provided in all regions of the UK.

Regional vascular surgical units: a practical means of providing specialist services.

A comprehensive regional emergency and elective vascular surgical service was established in Limerick Regional General Hospital between 1994 and 1996 following the appointment of three surgeons with vascular training. To compare vascular surgical activity before and after the establishment of a regional vascular service. This study used local and national computerised databases, clinic letters, theatre registers and radiology records to compare vascular surgical activity before (1992) and after (1997) this service was established. Total outpatient activity increased almost six-fold and total number of inpatient vascular procedures (including radiological) increased from 146 to 432, but the venous proportion declined from 70% to 36%. The number of major arterial procedures increased from 37 to 165 in 1997 including 10 carotid endarterectomies, 24 aortic reconstructions and 54 lower limb reconstructions representing rates of 3/100,000, 8/100,000 and 17/100,000 population respectively. As substantial changes in disease patterns are unlikely, these data indicate that patients previously diverted elsewhere for therapy are now cared for within the health board region and that further increases in workload may be expected. We suggest that these data mandate the reallocation of resources to fund appropriately staffed and audited regional vascular units.

A plan for the NHS for the 21st century.

A plan for the NHS for the 21st century.

Continuing diagnostic challenge of acute appendicitis: evaluation through modified Alvarado score.

Acute appendicitis with protean manifestations may simulate almost any other acute abdominal illness and in turn may be mimicked by a variety of conditions. Progression of symptoms and signs is usual in contrast to the fluctuating course of some other diseases that lead to heavy morbidity and mortality. A practical score for the early diagnosis of acute appendicitis was established by Alvarado in 1986 and was assessed in this study for its accuracy in pre-operative diagnosis. The usefulness of this scoring system in reducing the evaluated negative appendicectomy rate of acute appendicitis in 91 patients, diagnosed by clinical parameters only, over a period of 12 months is determined. A total of 106 patients underwent Alvarado scoring in emergency surgical service at SK Institute of Medical Sciences, Srinagar Kashmir, India. The high scores in men and children were found to be an easy and satisfactory aid in the early diagnosis of acute appendicitis, but a high false-positive rate for acute appendicitis was found in women.

Identification of the motor vehicle accident victim who abuses alcohol: an opportunity to reduce trauma.

We hypothesized that a poor driving history and alcohol abuse, evident in a large number of people injured in automobile accidents, contribute to repeated injury, and that treatment for alcohol abuse may reduce vehicular trauma. Patients (N = 150) admitted to the emergency surgical service because of injury sustained in a motor vehicle accident (MVA) were tested for their blood alcohol concentrations, and they responded to a questionnaire concerning their prior driving and medical histories. Contrary to the assumption that motor vehicle injuries are isolated episodes, 68% of MVA patients had experienced a prior accident, and 43% had been injured in an MVA before the present event. Prior MVAs were associated with having been previously arrested for driving while intoxicated (DWI), with illegal drug use and with prior hospitalization. Of the MVA patients, 37% were intoxicated (blood alcohol concentration [BAC] > or = 100 mg/dl). Elevated BAC was associated with having been stopped for drinking, having a restricted license, having a DWI arrest, using illegal drugs and having a previous admission to a hospital. Prior MVAs, prior DWIs, elevated BAC and male gender formed the Louisville Alcohol Abuse Predictor Checklist and were independent predictors of alcohol abuse diagnosis, based on the patient's self-report of problems with alcohol. Forty-two percent of MVA patients were diagnosed as alcohol abusers. The alcohol abuser had a significantly higher rate of recurrent MVAs, DWIs and injuries than did nonabusers. Surgical service may present an opportunity for assessment of alcohol abuse among MVA victims, and treatment for alcoholism might reduce vehicular trauma.

Positive behavioral support for people with brain injury: the Virginia experience

The effects of an acquired brain injury may impede an individual's ability to achieve meaningful employment and live independently. Unfortunately, existing community-based services are often inadequate or inappropriate to meet the needs of people with brain injury. As the number of people with brain injury increases due to advances in emergency medical and surgical care, survivors, family members, and service providers seek ways to meet the needs of people with brain injury beyond the acute recovery stage. The need for effective brain injury rehabilitation services is especially critical for individuals with challenging behaviors. In Virginia, a non-aversive, community-based support team approach known as Positive Behavioral Support (PBS) is being used with persons with brain injury. This approach, initially used with individuals with developmental and other severe disabilities, appears to have potential as an effective approach to working with people with acquired brain injury who have difficult behaviors. The first time that the Positive Behavioral Support model was utilized specifically with persons with brain injury was in 1992 when the Virginia Department of Rehabilitative Services, in collaboration with the Virginia Institute for Developmental Disabilities, a University Affiliated Program, implemented a one-year federally-funded project called PITON ('Positive Intervention and Training Outcomes Network'). At the time of the PITON project, eighteen states including Virginia had implemented this innovative behavioral approach, mostly with people with developmental disabilities. This article provides a brief overview of the Positive Behavioral Supports approach, as well as two case studies describing the use of PBS with persons with brain injury in Virginia.