Impact of a dedicated emergency surgical service on appendicitis outcomes

Abstract

Aim: The Emergency Surgery and Trauma (ESAT) team is a dedicated consultant-led service to streamline the emergency surgical workload in Singapore. As acute appendicitis is one of the most common acute surgical conditions, we aim to compare outcomes of patients with appendicitis in the ESAT model as compared to the traditional on-call model. Methods: A retrospective review of patients admitted to Khoo Teck Puat Hospital, Singapore, with acute appendicitis between two periods: May-October 2014 (6 months pre-ESAT) versus January-June 2017 (post-ESAT). Patient demographics, operative details, efficiency, clinical outcomes, and hospital bill savings were evaluated. Results: There were 192 patients in the pre-ESAT period and 179 patients in the post-ESAT period. Patient demographics and comorbidities were comparable (P > 0.05). Time from emergency department referral to surgical review was significantly reduced in the ESAT period: 77.8 AE 46.9 min versus 127 AE 102 in the pre-ESAT period (P = 0.002). Time from case booking to operating theatre was significantly shorter in the ESAT period: 72.4 AE 55.2 min compared to 157.3 AE 209.1 (P < 0.01). More cases were carried out in the daytime during the ESAT period, 50.2% versus 39.1% (P = 0.029). The majority underwent laparoscopic appendectomy 156/179 (87.2%) in the ESAT period, with fewer open appendectomies 3/179 (1.7%) as compared to the pre-ESAT period (P = 0.062). There were higher intraoperative consultant supervision rates during the ESAT period, 38/166 (22.9%) as compared to 12/166 (6.7%) in the pre-ESAT period (P = 0.001). There were fewer complications (Clavien-Dindo grade II and above) in the ESAT period, 1 (0.6%) as compared to 6 (3.4%) pre-ESAT (P = 0.07). Conclusion: The ESAT service is associated with better efficiency outcomes for patients with acute appendicitis.

Interventions to improve consultations in the emergency department: A systematic review

“…The majority of the included studies were conducted in North America (United States n = 12, 16–28 Canada n = 6 29–34 ) with a smaller number of studies conducted in Asia (South Korea n = 5, 35–39 Singapore n = 2, 40,41 Thailand n = 1, 42 Taiwan n = 1, 43 India = 1 44 ) and Europe (Ireland n = 1, 45 Turkey n = 2, 46,47 ; see Table 1). The studies were mainly conducted in a single ED site 16–25,27,29–32,34–50 . The majority of studies utilized a before/after study design ( n = 25, 71%), of which one study used a controlled before/after design 39 .…”

“… 22,23,32,40,42–45,48 These interventions aimed to increase the availability of a specific consultation specialty to the ED or improve the awareness and appropriate use of a consultation specialty/multidisciplinary team and/or expand the role of an existing consultation service. Five of the nine studies implemented surgical specialized care teams within the ED, 32,40,42,43,48 with two of these five studies specifying an increased availability of a surgeon to provide consults for nontraumatic surgical presentations 32,43 . Three studies focused on psychiatric specialized care teams, 22,23,44 with one study stationing a psychiatric resident in the ED from 9 a.m. to 8 p.m 44 .…”

“…Three studies assessing specialized surgical teams reported on consult response time 32,40,48 . Two studies reported a significant decrease in consult response time in the intervention group compared to control, 32,40 with MD reductions of −41.50 (95% CI –78.49 to –4.51) 32 and − 49.20 (95% CI −65.18 to –33.22 40 ; see Table 2 and Figure 2).…”

Initial emergency laparotomy outcomes following a transdisciplinary perioperative care pathway in Singapore

“…With the implementation of an ACS service in our institution, the emergency workload is streamlined to encourage productivity and efficiency and to improve clinical outcomes. 10 There was no additional staffing of the ACS service during the ELAP period compared to the pre‐ELAP period.…”

“…It is a consultant‐led service with dedicated junior staff attached to the team, comprising on average two specialists and six junior staff. With the implementation of an ACS service in our institution, the emergency workload is streamlined to encourage productivity and efficiency and to improve clinical outcomes 10 . There was no additional staffing of the ACS service during the ELAP period compared to the pre‐ELAP period.…”