Emergency general surgery models in Australia: A cross-sectional study

Abstract

Background Emergency general surgery (EGS) patients experience superior outcomes when cared for within an acute surgical unit (ASU) model. However, the EGS structures in most Australian hospitals remain unknown. Aims This study aimed to describe the national spectrum of EGS models. Methods Surgical staff were contacted in all Australian public hospitals of medium (>2,000 patient separations perannum) or greater peer group. Primary outcomes were incidence of each EGS model. Secondary outcomes were the relationship of EGS model to objective hospital variables, and qualitative reasons for choice of model. An ASU allocated a general surgeon solely to EGS patients for ≥50 per cent of business hours. A Hybrid model did not have this feature, but provided either a doctor-in-training rostered solely to EGS for ≥50 per cent of business hours, or ≥2 protected theatre half-day EGS lists per week. Results One hundred and nineteen of 120 eligible hospitals participated (99 per cent). Sixty-four hospitals (54 per cent) reported utilising hybrid model. ASU implementation was significantly more common amongst hospitals of greater peer group (p<0.0001), bed number (p<0.0001), surgeon pool (p=0.0003) and trauma service sophistication (p=0.0002). Leading reported drivers for ASU commencement were aims to improve EGS patient care and decrease after-hours operating, while common barriers against ASU uptake were insufficient EGS patient load or surgeon on-call pool. Conclusion ASU or Hybrid models of care for EGS patients may be more widespread than currently reported. Introduction of such structures is heavily dependent on hospital and staff size, trauma subspecialisation and EGS patient throughput.

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

“…This structure allows surgeons to manage their clinical commitments more effectively without them being unduly burdened by the task of caring for acutely unwell surgical patients, during their rostered on‐call hours, alongside other clinical commitments. Studies evaluating patterns of care within a single institution pre‐ and post‐introduction of an ASU have demonstrated improved hospital resource utilization, reduced delays in elective surgery, increased efficiency in managing the surgical workload and improved allocation of dedicated theatre time for emergency surgical cases 4,5,7,9,10 . In saying this, there are currently no true comparative studies between different institutions, which employ the traditional model or ASU model, that elucidate real‐time evidence and avoid a single‐arm institutional bias.…”

“…A recent cross‐sectional analysis of Australian public hospitals conducted by Kinnear et al . 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 .…”

“…Likewise, greater consultant involvement may also lead to more advanced decision‐making preoperatively, which is reflected in the significantly reduced preoperative imaging rates (CT scans) in the ASU cohort compared to the traditional on‐call model 1,7 . An additional benefit of the consultant‐led model is that it affords greater teaching and learning opportunities for trainees and junior staff by way of direct supervision and close contact 9 …”

Factors influencing interhospital transfer delays in emergency general surgery: a systematic review and narrative synthesis

“…8,9 Yet despite these recommendations, only 54% of hospitals in Australia in 2019 were using an ASU or hybrid model, while the remaining 46% of hospitals continued to use a traditional on-call system. 10 Introduction of ASU or equivalent structure to a healthcare facility is heavily dependent on hospital size, staff numbers, trauma subspecialisation and EGS patient throughput. 10 Gaps in surgical coverage occur when hospitals are unable to provide around-theclock EGS service, with reasons including rural location, small bed size, non-teaching status, inconsistent surgeon coverage, lack of system for booking emergency cases and lack of anaesthesia availability overnight.…”

“…10 Introduction of ASU or equivalent structure to a healthcare facility is heavily dependent on hospital size, staff numbers, trauma subspecialisation and EGS patient throughput. 10 Gaps in surgical coverage occur when hospitals are unable to provide around-theclock EGS service, with reasons including rural location, small bed size, non-teaching status, inconsistent surgeon coverage, lack of system for booking emergency cases and lack of anaesthesia availability overnight. 11 It is not surprising that these findings coincide with the triggers for interhospital transfers, [12][13][14] and highlights the relationship between interhospital transfers and EGS coverage gaps.…”