Acute surgical unit improves outcomes in appendicectomy

Abstract

Background: Few large Australian studies have explored the impact of acute surgical unit (ASU) model in appendicitis.Methods: An ASU model commenced practice at our institution on 1 August 2012. In this retrospective cohort study, patients undergoing appendicectomy 2.5 years before (Traditional group) or after (ASU group) this date were compared. Primary outcomes were median length of stay, median time from emergency department referral to theatre start and proportion of cases performed in-hours. Secondary outcomes were rates of complications, open appendicectomy, consultant scrubbed for procedure, intensive care unit admission and re-presentation to emergency department within 30 days. Results: After removing those with incomplete data, 1214 patients were enrolled; 465 in the Traditional group and 749 in the ASU group. There were no significant baseline differences between groups. Compared with the Traditional group, ASU patients had similar length of stay (1.81 versus 1.81 days; P = 0.54) and time to theatre (0.59 versus 0.56 days; P = 0.14), but a greater proportion of in-hours operation (72% versus 79%; P = 0.014). The ASU group also experienced fewer complications (9% versus 6%; P = 0.031), fewer primary open (4% versus 1%; P < 0.0001) or conversion-to-open appendicectomies (6% versus 2%; P < 0.0005) and had superior rates of consultant scrubbed in theatre (21% versus 56%; P < 0.00001). Rates of intensive care unit admission (1% versus 1%; P = 0.72) and re-presentation were unchanged (5% versus 5%; P = 0.46). Conclusion: In our institution, the introduction of an ASU model was associated with more in-hours operations and safer care for patients undergoing appendicectomy.

Comparative analysis of emergency general surgery on‐call structure and its impact on emergency appendicectomy outcomes

“…This principle aligns with the results of this study, which showed that a greater proportion of consultant cases were performed in the ASU cohort. Consultant cases are thought to be associated with greater patient safety; lower operative complication rates and 30‐day re‐operation rates are frequently cited and such findings are attributed to the increased operating experience that consultants have in comparison with trainees 11,14 . However, these differences were not observed in our study and are a testimony to appropriately structuring the team hierarchy within the traditional model, that is, appendicectomy procedures are performed by trainees assisted by or supervised by a surgical fellow.…”

“…demonstrates that up to 46% of participating hospitals still operate within the traditional on‐call model for general surgery 9 . It remains to be defined whether this lack of change is related to an absence of evidence justifying the ASU model, or rather improvements and adaptations that have allowed surgical units to better manage their elective clinical workload with their on‐call commitments such that a quality acute surgical service is still delivered 11 . There are significant costs associated with implementing an ASU model; employment of additional full‐time consultants and dedicated clinical nurse consultants as well as operating theatre costs need to be considered 7 .…”

Outcomes of an acute care surgery model: a 10‐year follow‐up study

“…Most studies have demonstrated a reduction in after‐hours or overnight operating . For non‐elective appendicectomy, wait times to surgery and lengths of stay were either reduced or unchanged, as were rates of perforated appendicitis . Complication rates were reduced or unchanged .…”

“…[4][5][6][7][8][9][10][11][12][13] For non-elective appendicectomy, wait times to surgery and lengths of stay were either reduced or unchanged, [4][5][6][7][8]12,14 as were rates of perforated appendicitis. [4][5][6][7]14 Complication rates were reduced 5 or unchanged. 6,14 For non-elective cholecystectomy, wait times to surgery and lengths of stay were usually reduced following the implementation of an ACS model, 10,15 although most studies reported no difference in the complication rate.…”

Does emergency general surgery model affect staff satisfaction, training and working hours?

“…In Australia, 18 public hospitals have documented their EGS structures to date. However, staff satisfaction, 13 on-call frequency 7,14,15 and trainee operating experience [16][17][18][19][20][21] have been only rarely reported, and remain unknown for the remaining great majority of Australian hospitals. Furthermore, the Royal Australasian College of Surgeons recommends on-call ratios for surgeons and registrars be no more frequent than one-in-four.…”