Impact of a regional acute care surgery model on patient access and outcomes

Abstract

Background:The consolidation of acute care surgery (ACS) services at 3 of 6 hospitals in a Canadian health region sought to alleviate a relative shortage of surgeons able to take emergency call. We examined how this affected patient access and outcomes. Methods:Using the generalized linear model and statistical process control, we analyzed ACS-related episodes that occurred between 39 months prior to and 17 months after the model's implementation (n = 14 713).Results: Time to surgery increased after the consolidation. Wait times increased primarily for patients presenting at nonreferral hospitals who were likely to require transfer to a referral hospital. Although ACS teams enabled referral hospitals to handle a much higher volume of patients without increasing within-hospital wait times, overall system wait times were lengthened by the growing frequency of patient transfers. Wait times for inpatient admission were difficult to interpret because there was a trend toward admitting patients directly to the ACS service, bypassing the emergency department (ED). For patients who did go through the ED, wait times for inpatient admission increased after the consolidation; however, this trend was cancelled out by the apparently zero waits of patients who bypassed the ED. Regionalization showed no impact on length of stay, readmissions, mortality or complications. Conclusion:Consolidation enabled the region to ensure adequate surgical coverage without harming patients. The need to transfer patients who presented at nonreferral hospitals led to longer waits.Contexte : Le regroupement des services chirurgicaux d'urgence (SCU) dans 3 hôpitaux sur 6 d'une région sanitaire canadienne visait à contrer une relative pénurie de chirurgiens capables d'effectuer les interventions d'urgence. Nous en avons analysé l'impact sur l'accessibilité des services et sur les résultats chez les patients.Méthodes : À l'aide du modèle linéaire généralisé et d'un contrôle statistique des procédés, nous avons analysé les cas adressés aux SCU entre 39 mois précédant et 17 mois suivant l'entrée en vigueur du regroupement des services (n = 14 713).

Pro-con debate on regionalization of emergency general surgery: controversy or common sense?

“…Additionally, there are reports of small groups of hospitals in other countries such as Canada and Ireland where EGS care was regionalized. In Canada, regionalization of ACS to three out of six hospitals did not improve morbidity, mortality, LOS, or readmissions 80. Furthermore, it resulted in an increase in wait times from referral hospitals and from the ED to inpatient admission.…”

“…Overly prescriptive regionalization plans may also have the unintended consequence of reducing access to EGS care. Kreindler and colleagues,80 who examined the effect on EGS patients overall in a regionalized system within Canada of a hospital with ACS and six surrounding hospitals, found that wait times increased primarily for patients presenting at non-referral hospitals who were likely to require transfer to a referral hospital. They surmised from their data that those who presented to a non-system hospital had increased wait times due to those from the insystem hospitals being given priority when previously they may have been able to get adequate care at the originating hospital.…”

Regional consolidation of orthopedic surgery: impacts on hip fracture surgery access and outcomes

“…In keeping with our methodology in a prior study, 14 we defined the patient journey as beginning with the first presentation to a WRHA ED (time of registration) and including the index ED visit, any ED attendances occurring within 24 hours of this visit, the first subsequent in patient admission to any WRHA hospital and any subsequent acute care admissions reflecting inpatient transfers (transfer noted in the "transfer-to" field and/or admission occurring within 6 h of the previous discharge). We did not include transfers to rehabilitation units or facilities, as there were some concerns about data quality.…”

“…6 A Canadian study found that the consolidation of acute care surgery increased wait times owing to the time required to transfer patients who presented at nonreferral hospitals. 14 There is a lack of evidence on the impacts of consolidating orthopedic trauma surgery. In one Canadian health region, the consolidation of all high-acuity procedures at designated hospitals was associated with reduced LOS and no increase in mortality; however, this consolidation was not specific to orthopedic surgery and, furthermore, was accompanied by other major changes, such as a dramatic alteration to the nurse staffing model.…”

Specialization in acute care surgery in low-income and middle-income countries

“…The ACS specialty was first developed in 2005 through the American Association for the Surgery of Trauma (AAST) to address this trend of increasing surgical subspecialization and diminishing general surgical workforce in the USA. 14 Since then, ACS models have been developed in Canada, 15 Taiwan, 16 and Australia 17 as well.…”