Ir J Med Sci DOI 10.1007/s11845-014-1113-4
Time to surgical review: an assessment of the traditional model of emergency surgical care M. E. Kelly • C. Conlon • G. N. Le • G. J. Nason • E. Mansour • K. C. Conlon P. F. Ridgway
Received: 15 February 2014 / Accepted: 25 March 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Background The traditional model for emergency surgical care consists of an on-call team providing service to the emergency department, while simultaneously balancing the demands of elective work. Various newer models, such as the ‘‘surgeon of the week’’ aim to reduce the conflict between elective and emergency duties. Despite the recent focus on newer models, there remains no data on the effectiveness of the traditional model. We aim to assess the efficacy of the traditional model in a large regional hospital. Methods A retrospective study between July 2009 and March 2010 was performed. Primarily, we assessed the initial time to surgical consultation after emergency department referral. Secondarily, we evaluated the impact of time periods, days of week, and case-mix etiology on this consultation time. Results The overall median time to surgical consultation after emergency department referral was 30 min (N = 860, P = 0.709). However, the median time to consultation was 60, 30, and 20 min for daytime, evening and night time, respectively (*P \ 0.001). Trauma cases had a median time of 15 min, vascular had 45 min, neoplasm had 120 min, while other categories (upper and lower gastroenterology, and skin related) were 30 min (*P = 0.025). Discussion Newer models of acute surgical care have desirable outcomes in consultation times. However, regional and economical implications have a substantial impact on which model is feasible at local levels. We
M. E. Kelly (&) C. Conlon G. N. Le G. J. Nason E. Mansour K. C. Conlon P. F. Ridgway The Adelaide and Meath Hospital -Tallaght, Trinity College Dublin, Dublin, Ireland e-mail: [email protected]
demonstrated that the traditional model still remains effective in a large sized tertiary referral unit. Keywords Emergency care Emergency hospital service Hospital efficiency Surgical care
Background Emergency department (ED) overcrowding has reached a crisis point internationally, with a constant focus on a reduction in waiting times and hours spent on emergency trolleys. With increasing volume through the ED, there is an added pressure put on the on-call surgical team to facilitate prompt, efficient consultation and surgical care. Historically, the on-call surgical service comprised the consultant, senior trainee and junior trainee. The traditional model has the on-call team providing service to the ED while simultaneously balancing the usual demands of elective work. This model of care is still currently utilized in many hospitals and countries worldwide. However, in the last decade, several alternative models for the delivery of emergency surgical care have been developed to alleviate the conflict between elective and emergency duties with the hope to reduce ED waiting times [1, 2]. This has resulted in the development of an emergency surgery specialty in its own right in many countries [3, 4]. Alternatively, some institutions in the United Kingdom and Canada have employed a designated ‘‘emergency-only surgeon service’’ (acute care surgeon or surgeon of week system), which is a surgical team dedicated only to emergency work for a particular day or week. The team devote themselves to emergency only consultations and operations without the addition of planned elective work. The desired time for the initial doctor–patient
Ir J Med Sci
consultation time after ED assessment and referral has been extensively discussed recently. A reasonable targeted time for specialist consultation has been inferred internationally to be within 30 min after initial ED assessment, however, no official gold standard have been implemented at a national level to our knowledge [5–8]. Another alternative model of care to the traditional system is the ‘‘reduced elective’’ system. In this system, the elective workload for the surgeon on-call is significantly reduced to facilitate the expectant caseload from emergency admissions. Again some have proposed a targeted time for initial surgeon–patient consultation of 30 min during the daytime or 45 min at night . Regardless of structure of the newer models, the most significant improvement is that these services will be consultant-led and driven [1, 3]. Therefore, the efficiency in patient processing and improved teaching to surgical trainees is anticipated. Despite the current focus on the time to surgical consultation, there remains no robust data on the efficiency of the traditional model. The aim of this study was to assess the efficacy of our traditional system employed by our department in a large-sized regional hospital. The primary outcome chosen for evaluating efficacy was the time to first surgeon– patient consultation, which is hypothesized to be longer during weekday normal working hours (08.00–17.00), and shorter for patients presenting with trauma.
Methods Study institution The Emergency Department in the study hospital is a university affiliated tertiary referral center, assessing over 73,000 patients with approximately 1,800 surgical admissions per year . It has a population catchment area of approximately 500,000 people. The study hospital unit utilizes the traditional model of surgical care with an on-call team comprising of a general surgical consultant, senior and junior surgical trainees covering a 24-h shift (8am–8am). The junior trainee remains in-house throughout the night consulting and admitting patients from the ED, and is the first point of contact for the surgical team. All surgical consultations are initially seen by the junior surgical trainee. If the junior surgical trainee is unavailable, the senior surgical trainee and/or consultant on-call is contacted. The senior staff is available onsite during working hours and is offsite at night. He/she readily provides support to the junior trainee if required or if the junior trainee is already occupied elsewhere. Furthermore he/she is available throughout the night for consults and/or operations if necessary and is always present for trauma consultations. The on-call consultant is
kept informed and is available for all emergency operations. A formal ward round of patients admitted over night begins each morning at 07.00. The integrity of our model relies on our electronic handover, known as the surgical sign-out, to ensure the continuity of care and accurate transfer of patient information between teams on a daily basis. Study design Using the bespoke electronic surgical sign-out maintained by the Department of Surgery, we performed a retrospective cohort study of admitted surgical patients between the 1 July 2009 and 31 March 2010. Our electronic surgical sign-out has a strict template for handover of patient details each morning (Fig. 1). A previous study had shown that our electronic handover method was associated with a significant reduction in patient length of stay and provided better continuity of care . The full details of this surgical sign out are described elsewhere . In brief, the sign out includes patients in the ED who were seen or admitted by the on-call surgical team, and in-house patients with requiring surgical consultation. This template details the members of the team on-call, number of admission/ operations/consults, patient demographics (name, age, hospital number), time of referral, time of first surgeon– patient consultation, brief medical background, main presenting complaints, clinical examination finding, investigation results, presumed diagnosis, and management plan. The sign-out is compiled by the junior trainee on-call who subsequently emails it via the hospital’s secure intranet to relevant surgical staff by 07.00. Only hospital staff has access to the hospital intranet. A nominated member of the surgical department was appointed as the account administrator to ensure only relevant staff receive the electronic sign out, thus ensuring patient confidentiality. Study outcomes The primary outcome was the time to first surgical consultation, defined as the time taken from ED referral to the surgical service until the initial surgeon–patient consultation. The time to initial consultation was calculated using the data recorded on the surgical sign outs. Sub-group analysis of the primary outcome included whether the of time day, day of the week, or the referral pathology (casemix) impacted on consultation time. The day was divided into three time sections: daytime (8.00–17.00), evening (17.00–24.00) and night time (0.00–08.00). The time to surgical consultation was examined in context of each of these time sections, and similarly for each day of the week. We also calculated the time to initial surgeon–patient consultation for the different categories of the admission case mix including upper gastroenterology (peptic ulcer
Ir J Med Sci Fig. 1 Example of the strict templated surgical sign-out
disease, pancreatitis, biliary disease, perforations and obstructions), lower gastroenterology (appendicitis, colitis, perforations and obstructions), neoplasm, skin (cellulitis and abscess), vascular, trauma and others (non-specific abdominal pain, gynaecology, respiratory and urology). This study was retrospective, and participants were unaware that data would be analyzed at a later date; therefore potential bias of consultation times was not an issue. Statistics Independent variables were compared using the non-parametric Kruskal–Wallis test. Statistical significance was
denoted by a P value of\0.05. The results were reported as medians and interquartile ranges unless otherwise stated. All data were analyzed using IBM SPSS Statistics software (version 20).
Results During the 9-month study period, 274 electronic handovers were generated accounting for 1,002 admitted patients. 85.8 % (N = 860) were included in the study with complete data (recorded time of ED referral, time of consultation and diagnosis). The remaining 14.2 % were
Ir J Med Sci Fig. 2 Median consultation times for different time sections of the day
excluded from further analysis due to incomplete data (including missing time of referral, time to first surgeon– patient consultation, or diagnosis). 50 % of patients were males (N = 501), and 50 % were females (N = 501). The mean age was 44.3 years old (range 17–93). During the study period Tuesday was the busiest day, while Saturday had the least referrals. However, each day had the same median consultation time of 30 min overall (P = 0.709). When examining different time sections of the day, most referrals occurred during the evening (17.00–24.00) (N = 333), while the night time (0.00–08.00) section had the least number of referrals (N = 252). There was significant differences in the median (range) consultation times of 60 min (5–300) for the daytime (08.00–17.00), 30 min (20–350) for evening (17.00–24.00) and 20 min (10–300) for night time (0.00–08.00) (Fig. 2, P \ 0.001). Furthermore evaluation of pair-wise comparison among the three time groups showed that there was statistical significance in the median consultation times. According to the distribution of admission case mix (Table 1), most patients were referred with upper and lower gastroenterology pathology. The neoplasm category had the least volume of patient referral. 2.4 % of patients (N = 25) did not have the diagnosis recorded in the surgical sign outs, therefore were excluded from statistical analysis. When analyzing all the case mix groups together, the difference in median consultation times were statistically significance at 15 min for trauma, 45 min for vascular group and 120 min for the neoplasm case mix, while all other categories was 30 min (P = 0.025). However, when
Table 1 Distribution of the admission case mix Case types
N = 860
Skin (cellulitis and abscess)
Others (non-specific abdominal pain, gynecology, urology)
removing the neoplasm, vascular and trauma groups from the case mix, there was no significant difference in the median consultation times between the upper GI, lower GI, skin, and miscellaneous groups. To assess whether the neoplasm, vascular or trauma groups had caused the statistically significant result (P = 0.025), further pairwise comparisons between each of these three groups and those with 30 min median consultation time were performed. This evaluation showed that only the trauma group had a statistically significant difference in median consultation time (P = 0.008).
Discussion General surgery is a high volume specialty with a broad range of both emergency and elective procedures. There is
Ir J Med Sci
often difficulty in balancing the clinical commitments between emergency and elective workloads especially with the traditional model of surgical care. As a result over the last decade many hospitals have implemented alternative models for the delivery of acute surgical care such as the ‘‘reduced elective’’ or ‘‘emergency only’’ system, with a view to decrease conflicts in clinical duties, and ultimately reduce waiting times [11, 12]. Internationally, there has been extensive discussion and drive to reduce time taken to consult on surgical patients. Although there remains no clear agreement on the appropriate time, 30 min target times have been cited by several international studies as a reasonable time after initial ED assessment [9–12]. However, there is no objective consensus on which model is the ‘‘ideal’’ method to achieve such targets. Regional and economical variations therefore have a significant bearing on which model can is utilized. Surgery is becoming increasingly sub-specialized due to the rapid expansion of technologies, and complexities of care. The developing specialization of acute care surgery has emerged expeditiously, however, not smoothly. Many trainee surgeons perceived the specialty as a non-operative field. Although the majority of ED patients are cared and managed by acute care surgeons, the majority of the operations required are performed by specialist surgeons in the relevant area . This has resulted in significant effort by the American Association for the Surgery of Trauma to identify and develop a practice model that would incorporate general surgeons, trauma surgeons and surgical critical care surgeons into one specialty . However, there has been considerable obstacles due to technical and manpower to implement this service at a peripheral centers (regional hospital), with many still utilizing a traditional model . This study assessing the traditional model shows that the median time for patients waiting to be assessed by the surgical on-call team after ED referral was 30 min regardless of the day of the week. However, upon dividing the day into different time sections, we found that the median consultation time during the day time is significantly longer than the evening or night time (60 vs. 30 vs. 20 min, P \ 0.001). Furthermore, there are significant outliers which have protracted waiting times in the traditional model. This delay is attributed to the day-time work commitments of the on-call surgical team including outpatient clinics, theater lists, ward rounds, endoscopy list, etc. When compared with the ‘‘reduced elective’’ or ‘‘emergency-only’’ models used by other institutions, our median consultation time of 60 min during the day was longer than the desired international standards of 30 min [7, 8]. However, during the evening and night time when elective work is finished, the median time to consultation was 30 and 20 min, respectively. This is comparable to that
of the ‘‘reduced elective’’ model and international standards. On examining the impact of each individual case pathology (case mix) had on time to surgical consultation, we found that trauma had a significantly shorter consultation time of 15 min (P = 0.008) as compared to the other categories. This result was well within the targeted international standard, highlighting trauma as the top priority. In the current economic climate with healthcare budget cuts leading to reduction in hospital staffs and services, it is unlikely that employment of more general surgeons to fulfill the ‘‘reduced elective’’ or ‘‘emergency-only’’ models would be feasible. In our institution, a tertiary referral unit with a general surgical department of four general surgeons, each with their own planned elective theater, outpatients, endoscopy and inpatient lists, utilizing the abovementioned newer models of ED surgical care would have significant detrimental effects on the department with either the other three general surgeons increasing their workload to compensate a surgeon dedicated entirely to oncall services or the cancelling of elective lists resulting in longer outpatients procedural waiting times. We acknowledge that the ‘‘reduced elective’’ or ‘‘emergency-only’’ models are more desirable, but to function there is a need for more general surgeons to redistribute the work load. In the modern era, technology offers the potential of new innovative methods to improve and ensure high standards of clinical care. Accurate handovers plays a vital role in maintaining the continuity of patient care and safety. Our surgical sign-out has the additional benefit for re-evaluation of clinical diagnosis, and relevant management strategies . It also enables a smoother transition from on-call to normal daytime staff [14, 15]. We use an easy, inexpensive and low-tech template for the accurate handover of information. In addition this electronic handover has indirect uses including; education, audit and research. Studies have shown that surgical teams on-call spend on average 5.5 h (330 min) over the course of 24-h shift assessing ED referrals to decide whether patients require admission to hospital [17, 18]. Our electronic surgical sign-out records the ‘‘unseen work’’ of the surgical service and provides an overview of the work load and complexity of admissions and consultations. Our study has limitations. It was a retrospective study performed at a single institution and we acknowledge that it is likely that different models of emergency surgical delivery will suit different catchment areas and sizes. 14.2 % of patients were excluded from further analysis due to incomplete time data. The surgical sign out did not record the time that patients arrived in ED or the time taken to be admitted on to a ward or length of stay while in hospital. We acknowledge that this information would add significant insight to post-ED department care.
Ir J Med Sci
Conclusion We have shown that the traditional model of surgical care in our hospital achieves an acceptable overall median time to surgeon–patient consultation of 30 min. Trauma has a considerably shorter overall median of 15 min. Newer models of acute surgical care delivery with dedicated oncall only teams have shown to be more efficient and desirable. However, local and regional variations still have a considerable impact on which model is most feasible. Conflict of interest
All Author’s have no conflict of interest.
References 1. Deabe SA, MacLellan DG, Meredith GL et al (2010) Making sense of emergency surgery in New South Wales: a position statement. ANZ J Surg 80:139–144 2. Parasyn AD, Truskett PG, Bennett M et al (2009) Acute-care surgical service: a change in culture. ANZ J Surg 79:12–18 3. Leppaniemi A (2014) Organization of emergency surgery. Br J Surg 101:7–8 4. Bhagvan S, Civil I (2009) Acute care surgery: can New Zealand afford to wait? NZ Med J 122(1289):71–76 5. Sorbelli PG, El-Masry NS, Dawson PM et al (2008) The dedicated emergency surgeon: towards consultant based acute surgical admissions. Ann R Coll Surg Engl 90:104–108 6. Maa J, Gosnell JE, Carter JT et al (2007) The surgical hospitalist: a new solution for emergency surgical care? Bull Am Coll Surg 92:8–17
7. Qureshi A, Smith A, Wright F et al (2011) The impact of an acute care emergency surgical service on timely surgical decisionmaking and emergency department overcrowding. J Am Coll Surg 213(2):284–293 8. Hameed SM (2010) General surgery 2.0: the emergence of acute care surgery in Canada. Can J Surg 53(2):79–83 9. (2010) The Health Service Executive. HSE Annual Report. http:// www.hse.ie/eng/services/newscentre/Annualreport2010.pdf 10. Ryan S, O’Riordan JM, Tierney S et al (2011) Impact of a new electronic handover system in surgery. Int J Surg 9:217–220 11. The Royal College of Surgeons of England. Safe handover: guidance from the working time directive working party. London RSCE, http://www.rcseng.ac.uk/publication/docs;2007 12. Cheah PL, Amott DH, Pollard J et al (2005) Electronic medical handover: towards safer medical care. Med J Aust 183(7):369–372 13. Jurkovich GJ (2007) Acute care surgery: the trauma surgeon’s perspective. Surgery 141(3):293–296 14. The Committee to develop the reorganized specialty of (2005) Trauma, surgical critical care and emergency surgery. Acute care surgery: trauma, critical care and emergency surgery. J Trauma 58:614–616 15. Hill BR, Nirula R (2010) The triad of trauma, emergency surgery and surgical critical care: practice patterns and financial considerations. Scand J Surg 99:64–67 16. Borley NR, Steer SE, Collins RE (1995) Unseen on-call workload of a general surgical team. Ann R Coll Surg Engl 77:189–190 17. Phillips H, Morris PJ (2003) The Royal College of Surgeons of England and the European Working Time Directive—a policy. London RCS www.rcseng.ac.uk/publications/docs/ewtd_policy_ statement.html 18. Raptis DA, Fernandes C, Chua W et al (2009) Electronic software significantly improves quality of handover in a London teaching hospital. Health Inform J 15(3):191–198