Surg Today DOI 10.1007/s00595-013-0775-2
ORIGINAL ARTICLE
A model-based evaluation of the Canberra Hospital Acute Care Surgical Unit Acute care surgery: a case of one size fits all? C. J. Beardsley • T. Sandhu • S. Gubicak • S. V. Srikanth • K. P. Galketiya • F. Piscioneri
Received: 5 January 2012 / Accepted: 17 April 2013 Springer Japan 2013
Abstract Purpose Surgical services in Australia are under sustained and growing pressure. The global implementation of acute care surgery services has been shown to facilitate the timeliness of acute surgery. The question is: Do acute care surgical units fit major regional centers like ours? The current study coincides with the introduction of a Surgical Assessment and Planning Unit (SAPU) at the Canberra Hospital and compares patient outcomes before vs. after the introduction of the SAPU, using acute appendicitis as the model illness. Methods We reviewed patients presenting to the Canberra Hospital Emergency Department with a preliminary diagnosis of acute appendicitis before vs. after the introduction of an acute care surgical unit. Results The subjects were 150 patients, ranging in age from 16 to 97 years. The mean time from presentation at casualty to surgical review and the surgical review itself was reduced by 19 and 26 %, respectively (p \ 0.05). Time to the operating table and the percentage of afterhours operations were reduced by 8 and 40 %, respectively. There was a significant reduction in the utilization of abdominal ultrasonography after the implementation of the SAPU.
C. J. Beardsley (&) T. Sandhu S. Gubicak F. Piscioneri The Australian National University, Peter Baume Building 42, Canberra, ACT 0200, Australia e-mail: [email protected]; [email protected] C. J. Beardsley S. Gubicak S. V. Srikanth K. P. Galketiya F. Piscioneri Department of General Surgery, Canberra Hospital, Canberra, Australia
Conclusions The implementation of a SAPU has benefited the management of patients with acute surgical conditions. Ultimately, patient care is enhanced, with patients being reviewed, admitted, and treated earlier. Keywords Acute care surgery Emergency medicine and surgery General surgery
Introduction The public health system in Australia has long been under considerable pressure, facing the challenges of an ageing population, increasing budgetary pressures, and a push for greater hospital efficiency. The state of the nation’s public hospitals led to the New South Wales state government sanctioned ‘‘Garling Report’’. This drew much publicity to the issue and added extra scrutiny to a health system already under considerable pressure. The Garling Report reflects similar recent statements from both New Zealand and the UK, calling for clinical leadership and the involvement of trained medical practitioners in the management and design of health services [1]. There have been several ramifications of the Garling Report to the delivery of acute care services in the public health system and the delivery of acute care surgery has not escaped such scrutiny. This report concluded that a new surgical model of care needed to be implemented to maximize the safety and efficiency of acute care surgery in New South Wales. There were two major ramifications to the provision of acute care surgery. First, it recommends the separation by facility, or operating list or otherwise, of planned or elective surgery from emergency or urgent unplanned surgery [2]. Second, the introduction of an Acute Surgery Unit was proposed. This is a consultant-led unit, the purpose of which is to
123
Surg Today
complete all acute surgery at the hospital within the 12-h daytime period [2]. There are many proponents of this concept, with its chief claim being greater efficiency in dealing with acute surgical patients. A separate and dedicated ‘Emergency Team’ can manage acute general surgical admissions efficiently as it permits elective work to carry on uninterrupted, reduces the number of operations performed after midnight, and provides a better environment for teaching and training [3]. The Canberra Hospital is a 600 bed tertiary referral centre for the Australian Capital Territory and South-East New South Wales, servicing a population of over 540,000. In September 2010, a Surgical Assessment and Planning Unit (SAPU) was launched in the hope that it will streamline potential acute surgical candidates; thus reducing overall patient waiting times, and enhancing management and the use of hospital resources. The SAPU is a 16-bed acute care ward with the following staff: •
Medical staff – – – – – – –
•
Clinical director On-call surgeon of the day SAPU Senior Registrar SAPU Registrar (Accredited trainee of the Royal Australasian College of Surgeons) Trauma Registrar (24-h cover) Dedicated consultant anaesthetist Junior Medical Officer (24-h cover)
Since its implementation in September, 2010, a total of 363 patients have undergone appendicectomy under the care of the staff of this new unit.
Methods This retrospective study tracked all patients who underwent appendicectomy between March and June in 2010 and 2011. Operation lists and handover sheets were scanned to locate potential patients during these months. After seeking departmental approval, the CRIS database system of the Canberra Hospital was utilised to retrieve patient data. Criteria for inclusion into the study were that the patient underwent appendicectomy and that histology was confirmed. Exclusion criteria were an age under 16 and serious pathology such as cecal carcinoma discovered at the operation. Table 1 outlines how the outcomes were measured. ‘‘Triage’’ was defined as the time when the patient was assessed by an Emergency Department (ED) triage nurse. ‘‘Casualty doctor review’’ was defined as the time the patient was first seen by an ED intern, resident, registrar, or consultant. ‘‘Time of operation’’ was when the first skin incision was made. We used Microsoft Excel for data entry and statistical calculations. The unpaired Student’s t test was used for determining significance of quantitative data, whereas Pearson’s Chi-square test was used for qualitative data. A p value of 0.05 was regarded as significant.
Nursing staff – – – –
One clinical nurse consultant (CNC) dedicated to SAPU full-time Monday to Friday One clinical development nurse (training, education, and support) 23 registered nurses 4 enrolled nurses
Results A total of 150 patients met the inclusion criteria for analysis. There was a greater predominance of females in the Table 1 Outcome measures
The consultant, registrar, and CNC review potential surgical candidates in the ED proactively by performing several rounds of the ED throughout the day to seek patients with a potential surgical diagnosis. The target for maximum stay was set at 48 h, with patients being transferred to a general surgical ward post-treatment or for observation if no diagnosis has been made within 48 h. The SAPU has a dedicated operating room for at least half of every working day. The previous system at the Canberra Hospital was the more traditional ‘on call’ system, where patients are admitted under staff specialists and treated by the team of that specialist. However, increasing numbers of older, sicker patients presenting at emergency departments, often requiring emergency surgical intervention, are more common. This requires a continuous workforce of surgical specialists to respond, evaluate, operate, and deliver critical care [4].
123
Outcome
Definition
Time to casualty doctor review
Time from triage to casualty doctor review by the intern, resident, or consultant
Time to general surgical review
Time from triage to the general surgical review by the registrar or consultant
Time from casualty to surgical review
Time from casualty doctor review to surgical review
Time to operating table
Time from triage until operation
Time to discharge
Time from triage until patient discharge
After-hours operating
Percentage of cases performed between 1800 and 0700 hours
Percentage of radiological investigations per patient
Number of radiological investigations ordered per patient population
Surg Today Table 2 Characteristics and clinical outcomes of patients undergoing appendicectomy at the Canberra Hospital (May–June, 2010 and 2011) 2010
2011
Number
84
66
Mean Age (range)
30 (16–72)
29 (16–97)
Sex distribution (male:female)
31:53
32:34
2010 cohort (Table 2), but the mean ages were similar in the two groups. All outcome measures except time to casualty review changed, as expected because this intervention does not impact on initial casualty review times. All outcome measures improved after introduction of the SAPU. Time to surgical review, casualty to surgical review, after-hours operating, and time to operating table were reduced significantly (Table 3). The time to discharge and the negative appendicectomy rate decreased by 10 and 6 %, respectively; however, the difference was not significant. There was a reduction by 12 % in the percentage of patients undergoing radiological investigations (50 vs. 44 %), but a sub-group analysis revealed that the reduction in investigations ordered was only significant for abdominal ultrasonography. There was a 6 % reduction in the number of CT scans ordered, but this reduction was not significant. There was a 16 % reduction in the percentage of ultrasounds ordered and this reduction was significant (p \ 0.05). The average length of stay in the unit was 43 h and 15 min, which was significantly less than the 48-h target.
Discussion The Canberra Hospital has benefited from the implementation of an acute care surgical system. Being a major
tertiary referral centre for both the ACT and South-East NSW, it draws a large proportion of trauma and surgical patients requiring urgent surgical care. The average length of stay in the SAPU was reduced to 43 h; well below the 48-h target. Moreover, there were significant reductions in the time patients waited to see surgeons, and between the casualty doctor review and the surgical review. Earlier assessment by the surgical registrar and fellow resulted in earlier operations and the more efficient use of radiological investigations, particularly abdominal ultrasonography. Not only were patients operated on earlier, but also at more reasonable hours, with a reduction in after-hours operating by 40 %. These reductions have significant flow-on benefits, reducing elective surgery delays, enhancing hospital resource utilization, and improving the teaching environment [3]. These benefits extend beyond the realm of surgical management, also helping to enhance ED patient flow. Similar results have been replicated at the Nepean, Prince of Wales, and John Hunter Hospitals in New South Wales, Australia. There has been special emphasis on the placement of a dedicated surgeon in the acute care surgical unit as a means for expediting and enhancing management [5–7]. The notion of acute care surgery also has the support of professional bodies and government health departments. The Royal Australasian College of Surgeons and General Surgeons Australia support the separation of acute (emergency) and planned surgery as an effective way of reducing the competition for beds [7]. Similar observations have been reported internationally. Maa et al. [8] reported a 50 % reduction in the wait time, from 16 ± 10 to 8 ± 4 h, from ED triage to skin incision for appendectomy in a 6-month period before and after the start of their ACS program (p \ 0.05). Britt et al. [9] reported that the service model has worked well for their acute care surgery service, with no substantial increase in complications or patient dissatisfaction, aided by the excellent working relationship between the surgeons on the team.
Table 3 Changes in outcome measures after the introduction of SAPU Outcome mean (standard deviation)
Pre-SAPU
Post-SAPU
% Change in end-point (a)
p value
Casualty review
2:48 ± 0:08b
2:49 ± 0:11
Unchanged
NS
Surgical review
6:07 ± 0:12
4:59 ± 0:08
19 (–)
\0.05
Casualty to surgical review
3:35 ± 0:14
2:39 ± 0:17
26 (–)
\0.05
Operating room
26:31 ± 1:34
24:29 ± 1:02
8 (–)
\0.05
After-hours operating
38 %
23 %
40 (–)
\0.05
Percentage of radiological investigations per patient
50 %
44 %
12 (–)
\0.05
CT investigation rate
18 %
17 %
6
NS
US investigation rate
32 %
27 %
16
\0.05
a
Denotes relative reduction
b
hours:minutes
123
Surg Today
We should mention that there are some detractors to the ACS concept, with a few authors citing that sub-specialization has been instrumental to the improved prognosis of trauma and patients with acute surgical illness [10]. Some have likened the concept of acute care surgery to what general surgery used to be [11]. Ball et al. [12] argue that there is no doubt that the recruitment and retention of Acute Care Surgeons will require money and thereby represent, initially at least, an increased cost to hospitals. A major problem with our unit was the limitation of a dedicated operating room for only half of the day, and an oncall consultant rather than a dedicated unit consultant. Our study had several limitations. First, our unit was assessed using appendicitis as a model surgical illness, but there are many other surgical conditions managed by the SAPU. Second, our study involved small sample sizes, which was probably responsible for the insignificant differences in reductions in time to discharge and the positive appendicectomy rate. Third, a greater proportion of female patients were included in the 2010 series, thereby biasing the positive appendicectomy rate and the percentage of radiological investigations ordered. Finally, the 3-month period leaves this study susceptible to temporal bias due to variable demand fluctuations throughout the year. In conclusion, our study was designed to assess the effectiveness of an acute care surgical unit in streamlining the management of patients with an acute surgical illness. We found that the implementation of this unit benefited all outcome measures for patients with appendicitis. Patients received better care and waited less time to be seen and treated. Moreover, it allows surgical teams to operate at more reasonable hours, reducing fatigue and increasing efficiency. While a substantial investment is required for the success of an acute care surgical unit, the enhancement of patient flow, reduction in delays to surgery, and more efficient utilization of hospital resources soon recuperate the costs.
123
References 1. Rankin D. The Garling Report: missed opportunities. Royal Australian College of Medical Administrator: the quarterly, vol. 42, no. 3. 2009. http://www.racma.edu.au/index.php?option= com_content&task=view&id=354&Itemid=523. Accessed 18 Aug 2010. 2. Garling P. Final Report of the Special Commission of Inquiry: Acute Care in NSW Public Hospitals, 2008—Overview. 1.173 State of NSW, Through Special Inquiry. http://healthactionplan. nsw.gov.au/files/garling-report/E_Overview.pdf. Accessed 20 Aug 2010 3. Addison PD, Getgood A, Paterson-Brown S. Separating elective and emergency surgical care (the emergency team). Scott Med J. 2001;46:48–50. 4. Earley AS, Pryor JP, Kim PK, et al. An acute care surgery model improved outcomes in patients with appendicitis. Ann Surg. 2006;4:498–504. 5. Cox M, Cook L, Dobson J, Lambrakis P, Ganesh S, Cregan P. Acute Surgical Unit: a new model of care. ANZ J Surg. 2010;80(6):419–24. 6. Parasyn A, Truskett P, Bennett M, et al. Acute-care surgical service: a change in culture. ANZ J Surg. 2009;79(1–2):6–7. 7. Garling P. Final Report of the Special Commission of Inquiry: Acute Care in NSW Public Hospitals, 2008. 23.80 A State of NSW, Through Special Inquiry. http://healthactionplan.nsw.gov. au/files/garling-report/E_Overview.pdf. Accessed 20 Aug 2010 8. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704–11. 9. Britt R, Weireter L, Britt L. Initial Implementation of an Acute Care Surgery Model: implications for timeliness of care. J Am Coll Surg. 2009;209(4):421–4. 10. Bosse M, Tornetta P, Sanders R, Swiontkowski M, Thoma R. Acute Care Surgery. J Trauma. 2005;59(4):1035–6. 11. Jurkovich GJ, Rozycki GS. Acute care surgery: real or imagined threat to the general surgeon. Am J Surg. 2010;199(6):862–3. 12. Ball C, Hameed M, Brenneman F. Acute care surgery: a new strategy for the general surgery patients left behind. Can J Surg. 2010;53(2):84–5.
ORIGINAL ARTICLE
A model-based evaluation of the Canberra Hospital Acute Care Surgical Unit Acute care surgery: a case of one size fits all? C. J. Beardsley • T. Sandhu • S. Gubicak • S. V. Srikanth • K. P. Galketiya • F. Piscioneri
Received: 5 January 2012 / Accepted: 17 April 2013 Springer Japan 2013
Abstract Purpose Surgical services in Australia are under sustained and growing pressure. The global implementation of acute care surgery services has been shown to facilitate the timeliness of acute surgery. The question is: Do acute care surgical units fit major regional centers like ours? The current study coincides with the introduction of a Surgical Assessment and Planning Unit (SAPU) at the Canberra Hospital and compares patient outcomes before vs. after the introduction of the SAPU, using acute appendicitis as the model illness. Methods We reviewed patients presenting to the Canberra Hospital Emergency Department with a preliminary diagnosis of acute appendicitis before vs. after the introduction of an acute care surgical unit. Results The subjects were 150 patients, ranging in age from 16 to 97 years. The mean time from presentation at casualty to surgical review and the surgical review itself was reduced by 19 and 26 %, respectively (p \ 0.05). Time to the operating table and the percentage of afterhours operations were reduced by 8 and 40 %, respectively. There was a significant reduction in the utilization of abdominal ultrasonography after the implementation of the SAPU.
C. J. Beardsley (&) T. Sandhu S. Gubicak F. Piscioneri The Australian National University, Peter Baume Building 42, Canberra, ACT 0200, Australia e-mail: [email protected]; [email protected] C. J. Beardsley S. Gubicak S. V. Srikanth K. P. Galketiya F. Piscioneri Department of General Surgery, Canberra Hospital, Canberra, Australia
Conclusions The implementation of a SAPU has benefited the management of patients with acute surgical conditions. Ultimately, patient care is enhanced, with patients being reviewed, admitted, and treated earlier. Keywords Acute care surgery Emergency medicine and surgery General surgery
Introduction The public health system in Australia has long been under considerable pressure, facing the challenges of an ageing population, increasing budgetary pressures, and a push for greater hospital efficiency. The state of the nation’s public hospitals led to the New South Wales state government sanctioned ‘‘Garling Report’’. This drew much publicity to the issue and added extra scrutiny to a health system already under considerable pressure. The Garling Report reflects similar recent statements from both New Zealand and the UK, calling for clinical leadership and the involvement of trained medical practitioners in the management and design of health services [1]. There have been several ramifications of the Garling Report to the delivery of acute care services in the public health system and the delivery of acute care surgery has not escaped such scrutiny. This report concluded that a new surgical model of care needed to be implemented to maximize the safety and efficiency of acute care surgery in New South Wales. There were two major ramifications to the provision of acute care surgery. First, it recommends the separation by facility, or operating list or otherwise, of planned or elective surgery from emergency or urgent unplanned surgery [2]. Second, the introduction of an Acute Surgery Unit was proposed. This is a consultant-led unit, the purpose of which is to
123
Surg Today
complete all acute surgery at the hospital within the 12-h daytime period [2]. There are many proponents of this concept, with its chief claim being greater efficiency in dealing with acute surgical patients. A separate and dedicated ‘Emergency Team’ can manage acute general surgical admissions efficiently as it permits elective work to carry on uninterrupted, reduces the number of operations performed after midnight, and provides a better environment for teaching and training [3]. The Canberra Hospital is a 600 bed tertiary referral centre for the Australian Capital Territory and South-East New South Wales, servicing a population of over 540,000. In September 2010, a Surgical Assessment and Planning Unit (SAPU) was launched in the hope that it will streamline potential acute surgical candidates; thus reducing overall patient waiting times, and enhancing management and the use of hospital resources. The SAPU is a 16-bed acute care ward with the following staff: •
Medical staff – – – – – – –
•
Clinical director On-call surgeon of the day SAPU Senior Registrar SAPU Registrar (Accredited trainee of the Royal Australasian College of Surgeons) Trauma Registrar (24-h cover) Dedicated consultant anaesthetist Junior Medical Officer (24-h cover)
Since its implementation in September, 2010, a total of 363 patients have undergone appendicectomy under the care of the staff of this new unit.
Methods This retrospective study tracked all patients who underwent appendicectomy between March and June in 2010 and 2011. Operation lists and handover sheets were scanned to locate potential patients during these months. After seeking departmental approval, the CRIS database system of the Canberra Hospital was utilised to retrieve patient data. Criteria for inclusion into the study were that the patient underwent appendicectomy and that histology was confirmed. Exclusion criteria were an age under 16 and serious pathology such as cecal carcinoma discovered at the operation. Table 1 outlines how the outcomes were measured. ‘‘Triage’’ was defined as the time when the patient was assessed by an Emergency Department (ED) triage nurse. ‘‘Casualty doctor review’’ was defined as the time the patient was first seen by an ED intern, resident, registrar, or consultant. ‘‘Time of operation’’ was when the first skin incision was made. We used Microsoft Excel for data entry and statistical calculations. The unpaired Student’s t test was used for determining significance of quantitative data, whereas Pearson’s Chi-square test was used for qualitative data. A p value of 0.05 was regarded as significant.
Nursing staff – – – –
One clinical nurse consultant (CNC) dedicated to SAPU full-time Monday to Friday One clinical development nurse (training, education, and support) 23 registered nurses 4 enrolled nurses
Results A total of 150 patients met the inclusion criteria for analysis. There was a greater predominance of females in the Table 1 Outcome measures
The consultant, registrar, and CNC review potential surgical candidates in the ED proactively by performing several rounds of the ED throughout the day to seek patients with a potential surgical diagnosis. The target for maximum stay was set at 48 h, with patients being transferred to a general surgical ward post-treatment or for observation if no diagnosis has been made within 48 h. The SAPU has a dedicated operating room for at least half of every working day. The previous system at the Canberra Hospital was the more traditional ‘on call’ system, where patients are admitted under staff specialists and treated by the team of that specialist. However, increasing numbers of older, sicker patients presenting at emergency departments, often requiring emergency surgical intervention, are more common. This requires a continuous workforce of surgical specialists to respond, evaluate, operate, and deliver critical care [4].
123
Outcome
Definition
Time to casualty doctor review
Time from triage to casualty doctor review by the intern, resident, or consultant
Time to general surgical review
Time from triage to the general surgical review by the registrar or consultant
Time from casualty to surgical review
Time from casualty doctor review to surgical review
Time to operating table
Time from triage until operation
Time to discharge
Time from triage until patient discharge
After-hours operating
Percentage of cases performed between 1800 and 0700 hours
Percentage of radiological investigations per patient
Number of radiological investigations ordered per patient population
Surg Today Table 2 Characteristics and clinical outcomes of patients undergoing appendicectomy at the Canberra Hospital (May–June, 2010 and 2011) 2010
2011
Number
84
66
Mean Age (range)
30 (16–72)
29 (16–97)
Sex distribution (male:female)
31:53
32:34
2010 cohort (Table 2), but the mean ages were similar in the two groups. All outcome measures except time to casualty review changed, as expected because this intervention does not impact on initial casualty review times. All outcome measures improved after introduction of the SAPU. Time to surgical review, casualty to surgical review, after-hours operating, and time to operating table were reduced significantly (Table 3). The time to discharge and the negative appendicectomy rate decreased by 10 and 6 %, respectively; however, the difference was not significant. There was a reduction by 12 % in the percentage of patients undergoing radiological investigations (50 vs. 44 %), but a sub-group analysis revealed that the reduction in investigations ordered was only significant for abdominal ultrasonography. There was a 6 % reduction in the number of CT scans ordered, but this reduction was not significant. There was a 16 % reduction in the percentage of ultrasounds ordered and this reduction was significant (p \ 0.05). The average length of stay in the unit was 43 h and 15 min, which was significantly less than the 48-h target.
Discussion The Canberra Hospital has benefited from the implementation of an acute care surgical system. Being a major
tertiary referral centre for both the ACT and South-East NSW, it draws a large proportion of trauma and surgical patients requiring urgent surgical care. The average length of stay in the SAPU was reduced to 43 h; well below the 48-h target. Moreover, there were significant reductions in the time patients waited to see surgeons, and between the casualty doctor review and the surgical review. Earlier assessment by the surgical registrar and fellow resulted in earlier operations and the more efficient use of radiological investigations, particularly abdominal ultrasonography. Not only were patients operated on earlier, but also at more reasonable hours, with a reduction in after-hours operating by 40 %. These reductions have significant flow-on benefits, reducing elective surgery delays, enhancing hospital resource utilization, and improving the teaching environment [3]. These benefits extend beyond the realm of surgical management, also helping to enhance ED patient flow. Similar results have been replicated at the Nepean, Prince of Wales, and John Hunter Hospitals in New South Wales, Australia. There has been special emphasis on the placement of a dedicated surgeon in the acute care surgical unit as a means for expediting and enhancing management [5–7]. The notion of acute care surgery also has the support of professional bodies and government health departments. The Royal Australasian College of Surgeons and General Surgeons Australia support the separation of acute (emergency) and planned surgery as an effective way of reducing the competition for beds [7]. Similar observations have been reported internationally. Maa et al. [8] reported a 50 % reduction in the wait time, from 16 ± 10 to 8 ± 4 h, from ED triage to skin incision for appendectomy in a 6-month period before and after the start of their ACS program (p \ 0.05). Britt et al. [9] reported that the service model has worked well for their acute care surgery service, with no substantial increase in complications or patient dissatisfaction, aided by the excellent working relationship between the surgeons on the team.
Table 3 Changes in outcome measures after the introduction of SAPU Outcome mean (standard deviation)
Pre-SAPU
Post-SAPU
% Change in end-point (a)
p value
Casualty review
2:48 ± 0:08b
2:49 ± 0:11
Unchanged
NS
Surgical review
6:07 ± 0:12
4:59 ± 0:08
19 (–)
\0.05
Casualty to surgical review
3:35 ± 0:14
2:39 ± 0:17
26 (–)
\0.05
Operating room
26:31 ± 1:34
24:29 ± 1:02
8 (–)
\0.05
After-hours operating
38 %
23 %
40 (–)
\0.05
Percentage of radiological investigations per patient
50 %
44 %
12 (–)
\0.05
CT investigation rate
18 %
17 %
6
NS
US investigation rate
32 %
27 %
16
\0.05
a
Denotes relative reduction
b
hours:minutes
123
Surg Today
We should mention that there are some detractors to the ACS concept, with a few authors citing that sub-specialization has been instrumental to the improved prognosis of trauma and patients with acute surgical illness [10]. Some have likened the concept of acute care surgery to what general surgery used to be [11]. Ball et al. [12] argue that there is no doubt that the recruitment and retention of Acute Care Surgeons will require money and thereby represent, initially at least, an increased cost to hospitals. A major problem with our unit was the limitation of a dedicated operating room for only half of the day, and an oncall consultant rather than a dedicated unit consultant. Our study had several limitations. First, our unit was assessed using appendicitis as a model surgical illness, but there are many other surgical conditions managed by the SAPU. Second, our study involved small sample sizes, which was probably responsible for the insignificant differences in reductions in time to discharge and the positive appendicectomy rate. Third, a greater proportion of female patients were included in the 2010 series, thereby biasing the positive appendicectomy rate and the percentage of radiological investigations ordered. Finally, the 3-month period leaves this study susceptible to temporal bias due to variable demand fluctuations throughout the year. In conclusion, our study was designed to assess the effectiveness of an acute care surgical unit in streamlining the management of patients with an acute surgical illness. We found that the implementation of this unit benefited all outcome measures for patients with appendicitis. Patients received better care and waited less time to be seen and treated. Moreover, it allows surgical teams to operate at more reasonable hours, reducing fatigue and increasing efficiency. While a substantial investment is required for the success of an acute care surgical unit, the enhancement of patient flow, reduction in delays to surgery, and more efficient utilization of hospital resources soon recuperate the costs.
123
References 1. Rankin D. The Garling Report: missed opportunities. Royal Australian College of Medical Administrator: the quarterly, vol. 42, no. 3. 2009. http://www.racma.edu.au/index.php?option= com_content&task=view&id=354&Itemid=523. Accessed 18 Aug 2010. 2. Garling P. Final Report of the Special Commission of Inquiry: Acute Care in NSW Public Hospitals, 2008—Overview. 1.173 State of NSW, Through Special Inquiry. http://healthactionplan. nsw.gov.au/files/garling-report/E_Overview.pdf. Accessed 20 Aug 2010 3. Addison PD, Getgood A, Paterson-Brown S. Separating elective and emergency surgical care (the emergency team). Scott Med J. 2001;46:48–50. 4. Earley AS, Pryor JP, Kim PK, et al. An acute care surgery model improved outcomes in patients with appendicitis. Ann Surg. 2006;4:498–504. 5. Cox M, Cook L, Dobson J, Lambrakis P, Ganesh S, Cregan P. Acute Surgical Unit: a new model of care. ANZ J Surg. 2010;80(6):419–24. 6. Parasyn A, Truskett P, Bennett M, et al. Acute-care surgical service: a change in culture. ANZ J Surg. 2009;79(1–2):6–7. 7. Garling P. Final Report of the Special Commission of Inquiry: Acute Care in NSW Public Hospitals, 2008. 23.80 A State of NSW, Through Special Inquiry. http://healthactionplan.nsw.gov. au/files/garling-report/E_Overview.pdf. Accessed 20 Aug 2010 8. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704–11. 9. Britt R, Weireter L, Britt L. Initial Implementation of an Acute Care Surgery Model: implications for timeliness of care. J Am Coll Surg. 2009;209(4):421–4. 10. Bosse M, Tornetta P, Sanders R, Swiontkowski M, Thoma R. Acute Care Surgery. J Trauma. 2005;59(4):1035–6. 11. Jurkovich GJ, Rozycki GS. Acute care surgery: real or imagined threat to the general surgeon. Am J Surg. 2010;199(6):862–3. 12. Ball C, Hameed M, Brenneman F. Acute care surgery: a new strategy for the general surgery patients left behind. Can J Surg. 2010;53(2):84–5.
