Impact of acute care surgery on timeliness of care and patient outcomes: a systematic review of the literature

Vergis, Ashley; Metcalfe, Jennifer; Stogryn, Shannon; Clouston, Kathleen; Hardy, Krista

doi:10.1503/cjs.010718

Cited by 11 publications

(12 citation statements)

References 38 publications

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“…As outlined by a recent systematic review on the impact of the ACS model on timeliness of care and patient outcomes, a lack of standard metrics and the absence of a dedicated comprehensive EGS database limit the ability to monitor performance and identify areas for quality improvement. 21 Although the ACS model has been a beacon of hope for addressing these issues, attention must be paid to timely access to the operating room. Other groups have found that even afterhours operating confers increased risk to patients undergoing general and vascular surgery.…”

Section: Discussionmentioning

confidence: 99%

Operative timing is associated with increased morbidity and mortality in patients undergoing emergency general surgery: a multisite study of emergency general services in a single academic network

Meschino

Giles

Rice

et al. 2020

CJS

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Background: Despite the widespread implementation of the acute care surgery (ACS) model, limited access to operating room time represents a barrier to the optimal delivery of emergency general surgery (EGS) care. The objective of this study was to describe the effect of operative timing on outcomes in EGS in a network of teaching hospitals. Methods: We conducted a retrospective review of EGS operations performed at 3 teaching hospitals in a single academic network. Time of operation was categorized as daytime (8 am to 5 pm), after hours (5 pm to 11 pm) or overnight (11 pm to 8 am). Time to operation was calculated as the interval from admission to operative start time and categorized as less than 24 hours, 24-72 hours and greater than 72 hours. Results: After we excluded nonindex cases, trauma cases and cases occurring more than 5 days after admission, 1505 EGS cases were included. We found that 39.0% of opera tions were performed in the daytime, 46.3% after hours and 14.8% overnight. In terms of time to operation, 52.3% of operations were performed within 24 hours of admission, 33.4% in 24-72 hours and 14.3% in more than 72 hours. The overall complication rate was 20.6% (310 patients) and the overall mortality rate was 3.8% (57 patients). After multivariable analysis, time to operation more than 72 hours after admission was inde pendently associated with increased odds of morbidity (odds ratio [OR] 1.64, 95% con fidence interval [CI] 1.09-2.47), while overnight operating was associated with increased odds of death (OR 3.15, 95% CI 1.29-7.70). Conclusion: Increasing time from admission to operation and overnight operating were associated with greater morbidity and mortality, respectively, for EGS patients. Strat egies to provide timely access to the operating room should be considered to optimize care in an ACS model. Contexte : Même si le modèle de chirurgie en soins actifs (CSA) est largement répandu, l'accès limité aux blocs opératoires représente un obstacle à la chirurgie générale chez les patients des services d'urgence (CGSU). L'objectif de cette étude était de décrire l'effet du moment de l'intervention sur l'issue des CGSU dans un réseau d'hôpitaux universitaires. Méthodes : Nous avons procédé à une revue des CGSU effectuées dans 3 hôpitaux d'enseignement d'un réseau universitaire. Le moment opératoire était catégorisé selon que les interventions étaient effectuées le jour (8 h 00 à 17 h 00), le soir (17 h 00 à 23 h 00) ou la nuit (23 h 00 à 8 h 00). Le délai opératoire représentait l'intervalle entre l'admission et le début de l'intervention et était réparti selon les catégories suivantes : moins de 24 heures, de 24 à 72 heures et plus de 72 heures. Résultats : Après exclusion des cas non index, des cas de traumatologie et des cas sur venus plus de 5 jours après l'admission, 1505 CGSU ont été incluses. Nous avons constaté que 39,0 % des interventions avaient été effectuées le jour, 46,3 % le soir et 14,8 % la nuit. Pour ce qui est du délai opératoire, 52,3 % des interventions ont été effectuées dans les...

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Section: Discussionmentioning

confidence: 99%

Operative timing is associated with increased morbidity and mortality in patients undergoing emergency general surgery: a multisite study of emergency general services in a single academic network

Meschino

Giles

Rice

et al. 2020

CJS

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“…The same surgeons were involved in the pre-ACS and R-ACS cohorts but the reduction in complications for AC might be explained by increased experience with laparoscopy during the study period or possibly by the conduct of these procedures at a tertiary teaching institution. Variation in study definitions and outcome measures for EGS conditions are common throughout the scientific literature [17]. This makes a direct comparison among study results challenging.…”

Section: Discussionmentioning

confidence: 99%

“…There are 13 ACS services in Canada with significant variation in organization and function [1,5]. The lack of standardization for ACS outcome measures and reporting makes comparisons among ACS services challenging [17-18]. Acute appendicitis (AA) and acute cholecystitis (AC) are the most common EGS diagnoses requiring admission [7], with standard, measurable points of care along the patient trajectory.…”

Section: Introductionmentioning

confidence: 99%

“…Standardization and consensus is required among ACS surgeons (and the health care teams/stakeholders involved in delivering care) to create an organized system of data capture and analysis to establish national standards for ACS service implementation and delivery, including support for evidence-based practice, quality improvement initiatives, as well as research, training/education, and innovation. Metcalfe et al [17] reported that approximately 27% (6/22) of studies of ACS implementation provided surgical response time and included five different definitions for this metric. Time to operating room was reported in 91% (20/22) of studies, with between five to seven distinct definitions while LOS was reported in 86% of studies with three separate definitions.…”

Section: Introductionmentioning

confidence: 99%

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The Impact of an Acute Care Surgical Service on the Quality and Efficiency of Care Outcome Indicators for Patients with General Surgical Emergencies

Hardy

Metcalfe

Clouston

et al. 2019

Cureus

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Background Acute care surgery (ACS) models address high volumes of emergency general surgery and emergency room (ER) overcrowding. The impact of ACS service model implementation on the quality and efficiency of care (EOC) outcomes in acute appendicitis (AA) and acute cholecystitis (AC) cohorts was evaluated. Methods A retrospective chart review (N=1,229) of adult AA and AC patients admitted prior to (pre-ACS; n=507; three hospitals; 2007) and after regionalization (R-ACS; n=722; one hospital; 2011). Results R-ACS time to ER physician assessment was significantly longer for AA (3.4 ± 2.3 versus 2.4 ± 2.6 hr; p ≤ 0.001). Surgical response times (1.3 ± 1.2 vs 2.6 ± 4.3 hr for AA; 1.8 ± 1.5 vs 4.1 ± 5.0 hr for AC; p ≤ 0.0001) and acquisition of imaging (4.1 ± 4.1 vs 6.9 ± 9.9 hr for AA, p ≤ 0.0001; 7.8 ± 1.9 vs 13.2 ± 18.5 hr for AC, p ≤ 0.008) occurred significantly faster with R-ACS. R-ACS resulted in a significant increase in night-time appendectomies (21.7% vs 11.1%; p ≤ 0.002), perforated appendices (29.1 % vs 18.9 %; p ≤ 0.006), 30-day readmissions (4.56% vs 0.82%; p ≤ 0.01), and lower rate of intraoperative complications for AC patients (2.78% vs 7.69%; p ≤ 0.02). Conclusions Despite the increased volume of patients seen with the implementation of R-ACS, surgical assessments and diagnostic imaging were significantly more prompt. EOC measures were maintained. Worse AA outcomes highlight areas for improvement in delivering R-ACS.

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“…1 Trauma and EGS patients treated at specialized trauma and newly established ACS centers have achieved superior clinical outcomes compared to patients treated in nonspecialized centers. [2][3][4][5] The COVID-19 pandemic has challenged health care systems and hospitals with an increased demand for both human and material resources and has presented a unique opportunity to test the performance of the ACS model during this nonsurgical catastrophic event. 6 During the COVID-19 surge in Boston from March to May 2020, the ACS service at an urban, tertiary, level I academic trauma center was assigned to continue coverage of all trauma, EGS, and SCC patients, with the added responsibility of taking care of critically ill nonsurgical patients including COVID-19 positive patients.…”

Section: Introductionmentioning

confidence: 99%

Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic

Bugaev

Hojman

Breeze

et al. 2020

The American Surgeon

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Background The role of an acute care surgery (ACS) service during the COVID-19 pandemic is not well established. Methods A retrospective review of the ACS service performance in an urban tertiary academic medical center. The study was performed between January and May 2020. The demographics, clinical characteristics, and outcomes of patients treated by the ACS service 2 months prior to the COVID surge (pre-COVID group) and during the first 2 months of the COVID-19 pandemic (surge group) were compared. Results Trauma and emergency general surgery volumes decreased during the surge by 38% and 57%, respectively; but there was a 64% increase in critically ill patients. The proportion of patients in the Department of Surgery treated by the ACS service increased from 40% pre-COVID to 67% during the surge. The ACS service performed 32% and 57% of all surgical cases in the Department of Surgery during the pre-COVID and surge periods, respectively. The ACS service managed 23% of all critically ill patients in the institution during the surge. Critically ill patients with and without confirmed COVID-19 infection treated by ACS and non-ACS intensive care units during the surge did not differ in demographics, indicators of clinical severity, or hospital mortality:13.4% vs. 13.5% ( P = .99) for all critically ill patients; and 13.9% vs. 27.4% ( P = .12) for COVID-19 critically ill patients. Conclusion Acute care surgery is an “essential” service during the COVID-19 pandemic, capable of managing critically ill nonsurgical patients while maintaining the provision of trauma and emergent surgical services.

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Impact of acute care surgery on timeliness of care and patient outcomes: a systematic review of the literature

Cited by 11 publications

References 38 publications

Operative timing is associated with increased morbidity and mortality in patients undergoing emergency general surgery: a multisite study of emergency general services in a single academic network

Operative timing is associated with increased morbidity and mortality in patients undergoing emergency general surgery: a multisite study of emergency general services in a single academic network

The Impact of an Acute Care Surgical Service on the Quality and Efficiency of Care Outcome Indicators for Patients with General Surgical Emergencies

Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic

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