Surgery (RMH) - Theses
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ItemImpact of consultant-led care on patient outcomes within an acute care surgical unit( 2016)Background and aims: Healthcare services globally are faced with having to respond to increasing demands of emergency surgery presentations. It is widely recognised that the care and management of emergency patients needs to be prioritised and improved. Consultant-led acute surgical units are being increasingly introduced as a means of addressing this need. To date, improvements in patient outcomes within the acute surgical unit model of care have been reported in the context of prevalent conditions such as acute cholecystitis and acute appendicitis. Studies involving all emergency general surgical conditions have been lacking. The aim of this study was to determine the impact of consultant-led model of care on patient outcomes within an acute care surgical unit at a tertiary centre. In addition to being inclusive of all emergency general surgical conditions, it aimed to report on multiple outcomes including: morbidity and mortality, timeliness of care, elective surgery workload and cancellation rate, as well as impact on surgical training and education. The workforce involved in provision of emergency general surgery at both trainee and consultant level was surveyed to determine current perceptions and future challenges facing consultant-led acute surgical units in Australia. Methods: A retrospective observational study of all consecutive emergency general surgical admissions in 2009-2012 was performed. A 2-year time frame before and after the establishment of the emergency general surgery (EGS) service was used to determine the number of admissions and operations, emergency department and hospital length of stay, as well as complication rates for all emergency general surgery patients. For patients presenting with acute benign biliary disease additional outcomes of time to theatre, rate of definitive surgical management during index admission, conversion from laparoscopic to open cholecystectomy rate, and use of diagnostic radiology in management of biliary disease was determined. On-line questionnaires were used to qualitatively assess the impact on the surgeons and trainees involved in provision of emergency general surgery. Results: The study included 7233 acute admissions. The EGS service managed 4468 patients (61·6 per cent increase) and performed 1804 operations (41·0 per cent increase). The most common diagnoses during the EGS period included acute appendicitis (532, 11·9 per cent), biliary disease (361, 8·1 per cent) and abdominal pain (561, 12·6 per cent). Appendicectomy (536, 29·7 per cent), cholecystectomy (239, 13·2 per cent) and laparotomy (226, 12·5 per cent) were the most commonly performed procedures. In the EGS period, time in the emergency department was reduced (from 8·0 to 6·0 h; P < 0·001), as was length of hospital stay (from 3·0 to 2·0 days; P < 0·001). The number of complications was reduced by 46·8 per cent, from 172 (6·2 per cent) to 147 (3·3 per cent) (P < 0·001), with a 53 per cent reduction in the number of deaths in the EGS period, from 29 (16·9 per cent) to seven (8 per cent) (P = 0·039). A total of 566 patients with benign biliary disease were further analysed (pre-EGS 254 vs. EGS 312). In the EGS period, the number of patients having surgery on index admission increased from 43.7 to 58.7 per cent (p < 0.001) as did use of intra-operative cholangiography from 75.7 to 89.6 per cent (p = 0.003). The conversion to open cholecystectomy rate was reduced from 14.4 to 3.3 per cent (p < 0.001). Overall, a 14 per cent reduction in use of multiple (>1) imaging modalities for diagnosis was noted (p = 0.003). There was a positive trend in reduction of bile leaks but no significant difference in the overall morbidity and mortality. Time to theatre was reduced by 1 day [pre-EGS 2.7 (IQR 1.5-5.0) vs. EGS 1.7 (IQR 1.2-2.6) p < 0.001]. The overall hospital LOS was reduced by 1.5 days [pre-EGS 5.0 (IQR 3-7) vs. EGS 3.5 (IQR 2-5) p < 0.001]. In the EGS period of the study, elective surgery workload increased by 23.7 per cent with a corresponding 16.9 per cent reduction in cancellation rates. Consultant presence in theatre, and surgical trainees’ primary operating role also increased by 12 and 21.5 per cent respectively. The surveys demonstrated overall support for the consultant-led model of acute surgical units. Impact on private practice, remuneration and need for appropriate resource allocation were highlighted as issues needing further consideration. Conclusions: 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.