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Aust. J. Rural Health (2015) 23, 155–160
Original Research Waiting for definitive care: An analysis of elapsed time from decision to surgery or transfer in a rural centre Hannah Dobson, MBBS, BMedSc,1 Weranja K.B. Ranasinghe, MBChB, MRCSED,1 Matthew K.H. Hong, MBBS, BMedSc,1 Liliana N. Bray, BMedSc(Hons),1 Manivannan Sathveegarajah, MD, BSc,1 Fatima Vally, MBBS, BMedSc,1 and Francis J. Miller, MBBS, PhD, FRACS1,2 1
Department of Surgery, Northeast Health Wangaratta, Wangaratta and 2Rural Health Academic Centre, Melbourne University, Melbourne, Victoria, Australia
Abstract Objective: To examine the timing of operative management and interhospital transfer of emergency general surgical patients in a regional setting. Design: Retrospective cohort study. Setting: The surgical unit at a major rural referral centre for North-Eastern Victoria servicing a population of 90 000. Participants: General surgical patients (n = 649) admitted via the emergency department at Northeast Health Wangaratta between January 2011 and March 2013 undergoing operative management (n = 608) or transfer to a tertiary centre (n = 44). Main Outcome Measures: Timing of operative management, using appendicectomy as a benchmark operation, was measured as time from presentation to decision to operate, time from decision to surgery, percentage after-hours operating and length of stay (LOS). Time to interhospital transfer was calculated and reasons for delay were sought. Results: Two hundred forty-six appendicectomies were performed. Median time from decision to operate to theatre was 3 hours (interquartile range (IQR) 2–8), and total LOS was 43 hours (IQR: 28–56). Two hundred seventy-two procedures (43%) were performed out-ofhours, including 48% of appendicectomies. Median
Correspondence: Dr Hannah Dobson, Department of Surgery, Northeast Health Wangaratta, 35–47 Green Street Wangaratta, Victoria, 3677, Australia. Email: [email protected] Ethics Approval: IRB: Northeast Health Wangaratta Human Research Ethics Committee. Accepted for publication 23 September 2014. © 2015 National Rural Health Alliance Inc.
time from decision making to transfer was 10.3 hours (IQR: 4.7–25). Transfer was less likely to be delayed in trauma patients when compared with urgent nontrauma patients (5.3 versus 10.6 hours; P = 0.04). Conclusion: Even in the absence of a strict four-hour rule program and a dedicated emergency surgical unit, main outcome measures appear to be comparatively efficient. However, the duration for transfer of patients is suboptimal because of the lack of established pathways for urgent non-trauma transfer from rural centres and bed availability in tertiary hospitals. KEY WORDS: acute care surgery, emergency surgery, patient transfer, rural health service.
Introduction The ever-increasing medical complexity of patients and an ageing population have led to a growing demand for acute surgical interventions and substantial strain on health-care systems.1–6 Acute surgical care models and emergency general surgery (EGS) units have been developed with the aim of increasing consultant-led patient care, dedicated in-hours emergency theatre lists and improved surgeon satisfaction.1,3,6–9 These have led to reductions in time to definite operative management, as measured by benchmark emergency procedures such as appendicectomy, cholecystectomy and hip joint replacements for femoral fractures.6–8,10–13 However, many of these studies are based on data from metropolitan hospitals. The practice of rural surgery bears unique challenges compared to those faced in tertiary centres. Wider scopes of practice, reduced critical care support and logistical problems associated with large distances from major hospitals contribute to potential differences in outcomes for rural surgical patients. The provision of ‘definitive surgical care’ in a doi: 10.1111/ajr.12160
156
What is already known on this subject: • There is a growing demand for acute surgical interventions, which has resulted in substantial strain on health-care systems. • Acute surgical models and emergency surgical assessment units have been developed to improve timely delivery of surgical care. • Much of the research supporting these units is based on data from large metropolitan hospitals, and the practice of rural surgery bears a number of unique challenges including wider scopes of practice and the need to transfer patients to tertiary centres.
rural centre thus entails a decision to operate urgently or transfer to a metropolitan centre for specialised care, a situation seldom encountered in the tertiary setting. Data from rural centres have generally been limited to subsets of patients, including major trauma or critically ill patients requiring transfer to intensive care units.14–16 This study presents the model of surgical care used at Northeast Health Wangaratta (NHW) and examines the timing of operative management and interhospital transfer of emergency general surgical patients. In addition, it examines the rate of after-hours operating in the absence of dedicated in-hours emergency operating lists.
H. DOBSON ET AL.
What this study adds: • This retrospective cohort study suggests that despite the absence of a strict four-hour rule program or dedicated emergency surgical unit, a rural surgical unit can manage emergency surgical conditions with at least comparable efficiency to metropolitan centres. • Resource allocation in rural surgical centres might be better focused towards development of pathways for urgent transfer of nontrauma, specifically with respect to bed availability in tertiary hospitals.
cal unit who required acute transfer to a tertiary centre for specialist care. Retrospective chart review was undertaken and data including age, gender, time of admission to the ED, hospital length of stay (LOS) and operative procedures were recorded. We defined an emergency general surgical procedure as any procedure required by a patient admitted to the general surgical unit following presentation to the ED. We excluded all patients with an unplanned return to theatre following an elective procedure. Further management at a tertiary centre was defined as patients requiring surgical or medical management unavailable at NHW. Medical records were unavailable for one patient.
Methods Patient population and surgical services NHW is a major referral health centre for NorthEastern Victoria, servicing a population of approximately 90 000 over 28 townships.17 The general surgical unit is staffed by four consultant surgeons, two registrars and two interns. The surgical on-call is run on a ‘consultant of the day’ model, and consultants cover one in four weekends. The hospital has 24-hour computed tomography availability and is able to provide 24-hour emergency surgery. There is no dedicated EGS unit and no operating theatre allocated exclusively for emergency surgery.
Data collection Following Human Research and Ethics Committee approval, we retrieved de-identified data from Health Information Services on all patients admitted via the NHW emergency department (ED) between 1 January 2011 and 31 March 2013 who required a surgical procedure or any patient admitted under the general surgi-
Timing of surgery or transfer In order to evaluate the performance of our emergency surgical service, we examined time from presentation to the ED to decision to operate, time to theatre, out-ofhours emergency theatre and hospital LOS.6,9 Appendicectomy was examined as a benchmark procedure for urgent surgery and an indicator of the emergency surgical workload to allow comparison with other models of surgical care.6,11,13 If patients received more than one operation during the admission, data were based on the initial procedure. For patients requiring interhospital transfer, we recorded time of admission, decision to transfer the patient and time of departure. We also recorded the mode of transportation. Patients were excluded if the time of decision to transfer could not be ascertained (n = 13). We defined a delay as any time for departure after decision for transfer was made beyond the minimum recorded transfer-out time of three hours. The reason for transfer was noted, and patients were separated into trauma and non-trauma groups. Where possible, the reason for any delay in transfer was recorded. © 2015 National Rural Health Alliance Inc.
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Types of surgery or transfer The study population was characterised by type of procedure. Procedures were classified according to whether they commenced during the day (0800–1700), the evening (1700–2200) or at night (2200–0800). We defined in-hours surgery as any procedure that commenced between 0800 and 1700, and out-of-hours surgery as any procedure commencing between 1700 and 0800.
Statistical analysis Data were reported as mean ± one standard deviation for normally distributed data or as medians and interquartile ranges (IQRs) where data were not normally distributed. The Student’s t-test was used to calculate the significance of difference between two means, while the Kruskal–Wallis test was used to determine the significance of difference between two medians. Analysis was performed with PASW Statistics 20.0 (formerly SPSS Inc, Chicago, IL, USA), and all tests were two sided with statistical significance assumed at P < 0.05.
Results Between January 2011 and March 2013, 634 patients were admitted via the ED requiring EGS or interhospital transfer, with four patients requiring surgery prior to transfer. Six hundred seven patients underwent 626 general surgical procedures. An average of 24 ± 6 emergency procedures were performed per month. Three hundred fifty-four patients (55.8%) were admitted in-hours. The average age of patients was 48 ± 25 years, with a range from 4 to 96 years.
Two hundred forty-four appendicectomies were performed (39%), with an average of 2.1 procedures performed per week. Of these, 221 (90.6%) were open procedures. Laparoscopic procedures were significantly biased towards female patients (22% male versus 78% female, P = 0.005).
Time to definitive surgery The overall median time to theatre was 12 hours (IQR: 4–25 hours) (Table 1). Of patients requiring appendicectomy, the median time from admission to theatre was nine hours (IQR: 4–19 hours). The time of decision to proceed to theatre was recorded in only 148 (60.7%) patients undergoing an appendiectomy. Of these cases, median time from presentation to the ED to the decision to operate was three hours (IQR: 1–12). Overall median hospital LOS was 49 hours (IQR: 28–129 hours) with median hospital LOS in patients requiring an appendiectomy of 43 hours (IQR: 28–56 hours). Two hundred sixty-six procedures (43.8%) were performed out-of-hours; 35 procedures (5.8) occurred at night. One hundred seventeen appendicectomies (48%) were performed after-hours, and nine (3.7%) occurred at night (Table 1).
Patients requiring transfer Thirty-one patients required transfer from NHW to a tertiary centre for definitive care (Table 2). The urgency for transfer differed among trauma patients from nonurgent single fractures to patients with multiple injuries. Similarly, non-trauma patients encompassed a range of
TABLE 1:
Outcomes of patients requiring an emergency general surgical procedure
Procedure
Total number
Time from ED to theatre Median (IQR), hours
Hospital LOS Median (IQR), hours
Post-op LOS Median (IQR), hours
Out-of-hours operating (%)
Nighttime operating (%)
Appendicectomy Adhesiolysis Bowel resection Cholecystectomy Oversew of perforation Abscess Hernia repair Other Endoscopic procedure Total
244 19 66 41 10 30 37 7 153 607
9 17 10 30 5 6 5 23 19 12
43 157 223 96 164 24 34 52 48 49
24 114 191 50 159 18 19 29 21 27
121 10 42 11 10 16 20 3 33 266
10 0 10 1 2 1 6 0 5 35
(4–19) (6–61) (6–28) (21–51) (3–8) (4–18) (3–8) (10–32) (5–40) (4–24)
(29–56) (98–227) (140–336) (72–167) (124–190) (21–46) (22–63) (48–93) (18–94) (27–119)
ED, emergency department; IQR, interquartile range; LOS, length of stay. © 2015 National Rural Health Alliance Inc.
(18–42) (82–166) (130–279) (41–122) (114–187) (14–27) (16–60) (17–83) (7–48) (18–94)
(49.6) (52.6) (63.6) (26.8) (100) (53.3) (54.1) (42.9) (21.6) (43.8)
(4.1) (0) (15.2) (2.4) (20) (3.3) (16.2) (0) (3.3) (5.8)
158 TABLE 2:
H. DOBSON ET AL.
Trauma versus non-trauma summary of transfers
Total number of patients Male Age (mean ± SD) Time from decision to transfer Median (IQR), hours
All patients requiring transfer
Trauma
Non-trauma
P-value
31 19 (61.3%) 49.3 ± 25.0 9.3 (4.6–20.4)
9 4 (44.4%) 36.7 ± 15.4 5.3 (3–8.0)
22 15 (68.2%) 54.5 ± 26.6 10.6 (5.9–23.7)
0.23 0.07 0.04
IQR, interquartile range; SD, standard deviation.
FIGURE 1: Timing of transfer: plot of times from decision making to transfer for trauma and non-trauma patients. Logarithmic scale used because of the long elapsed times seen in the nontrauma category. Median time for trauma patients (5.3 hours) was significantly less than that for non-trauma patients (10.6 hours), P = 0.04.
conditions including those requiring urgent intervention such as ischaemic limbs (n = 2, 9%), acute coronary syndromes in a surgical patient (n = 1, 5%), severe pancreatitis (n = 1, 5%) and septicaemia (n = 6, 27%). A median time of 9.3 hours (IQR: 4.6–20.4 hours) was noted from decision making to transfer out of the hospital, with delay commonly caused by lack of bed availability in the tertiary centre. Trauma patients were significantly less likely to experience such delays when compared with non-trauma patients (5.3 hours, IQR: 3–8.0 hours versus 10.6 hours, IQR: 5.9–23.7 hours; P = 0.04) (Fig. 1). Some urgent non-trauma conditions such as ischaemic limbs requiring vascular intervention were subjected to long transfer times including one of 26 hours.
Discussion The practice of rural surgery bears unique challenges to those faced in tertiary centres including wider scopes of practice, reduced critical care support and logistical problems associated with large distances from major hospitals. Our study has been limited to timing of care and did not examine complication rates. Hospital LOS was used as a surrogate marker of successful clinical management. The applicability of our data to other centres might be influenced by surgeon preference as demonstrated by a tendency to conservatively manage conditions such as acute cholecystitis and a penchant to
perform open appendicectomies. Additionally, the retrospective nature of the study is associated with inherent problems of incomplete documentation and recorder bias. Nevertheless, a comparison with data from larger centres highlights some advantages and disadvantages of rural surgery. Following the observation of increasing strain on health-care systems, the Four Hour Rule Program was implemented to combat ED overcrowding.18 With no strict implementation of the Four Hour Rule Program at NHW, the median time from ED admission to decision to operate for appendicitis was three hours and median time to theatre was nine hours. Cubas et al.10 reported a median time from hospital presentation to theatre of 11.0 hours. We performed a greater number of appendicectomies than Cubas et al.10 (average 1.7 appendicectomies per week versus 2.1 per week) and reported similar median hospital LOS (43.2 versus 43 hours). The majority of appendicectomies were open procedures, and this might have positively influenced our time to theatre. However, it has previously been documented that laparoscopic appendicectomy is associated with a comparable operative time.19 Our results suggest that, at least in a rural surgical setting similar to NHW, a model that allows patients to be prioritised and managed according to severity rather than according to their ED LOS can offer equal or better patient safety and quality of care compared to those reported in the literature. © 2015 National Rural Health Alliance Inc.
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In order to increase availability of daytime operative availability and meet caseload demands, hospitals can create capacity for emergency cases on elective lists, use evening and weekend theatre sessions for semi-urgent cases, and physically separate emergency and elective operating teams.1–6,9,20 However, it is recognised that it is not always possible to delay a procedure until the next morning. Following the introduction of EGS theatre sessions, McGlade et al.12 reported a reduction in time to theatre from 41.8 to 26.4 hours in patients requiring an acute cholecystectomy, and Lovett et al.21 documented a reduction in emergency cases occuring after-hours from 88% to 53%. NHW has the ability to perform 24-hour emergency surgery; however, it does not have rostered theatre staff for night nor a dedicated surgeon and surgical team for out-of-hours operating. The majority of nighttime operating at NHW was performed for urgent cases, as demonstrated with 121 appendectomies occurring out-of-hours and 4.1% at night. This highlights the importance and use of 24-hour emergency theatre availability and demonstrates the success of a rural surgical unit in the absence of dedicated EGS theatre sessions. Surgeon satisfaction might have significant bearing on the success of any surgical care model. It is possible that the high morale and willingness to readily transfer or accept care of patients among surgeons within the unit facilitates such an efficient use of theatre time. The analysis of patients undergoing interhospital transfer demonstrated potentially significant delays faced by rural patients unable to be managed by local services. Non-trauma patients experienced a median time from decision to transfer of 11 hours, whereas trauma patients had a median transfer time of five hours. Bed availability at the receiving hospital accounted for the majority of delays. While this demonstrates effectiveness of established trauma pathways, non-trauma surgical emergencies such as limb ischaemia requiring vascular intervention had transfer times of up to 26 hours, placing greater burden on rural surgical teams who must manage these patients without necessary equipment, subspecialty expertise or critical care support. Thus, more resources towards bed availability at tertiary centres is required to provide optimal surgical care for patients.
Conclusion Providing definitive care in a major rural surgical referral centre such as NHW involves unique challenges including the need for interhospital transfer. In the absence of a strict four-hour rule program or a dedicated EGS unit, critical factors such as time from presentation to theatre, nighttime operating and LOS appear to be comparatively efficient. An emphasis on management © 2015 National Rural Health Alliance Inc.
based on clinical severity rather than ED LOS contributes to the efficiency of the surgical unit at NHW. However, timely transfer of non-trauma surgical patients requiring specialist care appears to be limited by bed availability in receiving hospitals. Resource allocation in centres such as NHW might be better focused towards development of pathways for urgent transfer of non-trauma patients.
Acknowledgements There are no declarations by any author of competing interests, financial or otherwise.
References 1 Garland AM, Riskin DJ, Brundage SI et al. A county hospital surgical practice: a model for acute care surgery. American Journal of Surgery 2007; 194: 758–763, discussion 63–4. Epub 2007/11/17. 2 Garling P. Final report of the Special Commission of Inquiry: acute care services in NSW public hospitals, 2008. 3 Poole GH, Glyn T, Srinivasa S, Hill AG. Modular acute system for general surgery: hand over the operation, not the patient. ANZ Journal of Surgery 2012; 82: 156–160. 4 Rowe P, Lawrence W, Fellows E. The management of emergency surgical patients in a surgical assessment unit. Annals of the Royal College of Surgeons of England 2003; 85: 274–277. 5 Trompetas V, Sandison A, Saunders M, Gurjar S. Morning or afternoon emergency list? Effects on service provision and training. International Journal of Surgery 2009; 7: 28–30. 6 Williams D, Cronin C, McCarthy C et al. Good practice in emergency surgery: a literature review. Victoria: Performance, Acute Programs and Rural Health Branch, 2010. 7 Earley AS, Pryor JP, Kim PK et al. An acute care surgery model improves outcomes in patients with appendicitis. Annals of Surgery 2006; 244: 498–504. 8 Gandy RC, Truskett PG, Wong SW, Smith S, Bennett MH, Parasyn AD. Outcomes of appendicectomy in an acute care surgery model. Medical Journal of Australia 2010; 193: 281–284. 9 Parasyn AD, Truskett PG, Bennett M et al. Acute-care surgical service: a change in culture. ANZ Journal of Surgery 2009; 79: 12–18. 10 Cubas RF, Gomez NR, Rodriguez S, Wanis M, Sivanandam A, Garberoglio CA. Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: impact on timing and cost. Journal of the American College of Surgeons 2012; 215: 715–721. 11 Faiz O, Banerjee S, Tekkis P, Papagrigoriadis S, Rennie J, Leather A. We still need to operate at night! World Journal of Emergency Surgery 2007; 2: doi:10.1186/1749-7922-229. 12 McGlade DP, Watters DA, Stupart DA. Emergency surgery model improves outcomes for patients with acute cholecystitis. Medical Journal of Australia 2013; 198: 413.
160 13 Schuster KM, Davis KA, Rosenbaum SH. Emergency and urgent surgery. Medical Clinics of North America 2009; 93: 1131–1148. 14 Flabouris A, Hart GK, George C. Outcomes of patients admitted to tertiary intensive care units after interhospital transfer: comparison with patients admitted from emergency departments. Critical Care and Resuscitation 2008; 10: 97–105. 15 Flabouris A, Hart GK, Nicholls A. Patients admitted to Australian intensive care units: impact of remoteness and distance travelled on patient outcome. Critical Care and Resuscitation 2012; 14: 256–267. 16 Zalstein S, Danne P, Taylor D et al. The Victorian major trauma transfer study. Injury 2010; 41: 102– 109.
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17 NHW. Northeast Health Wangaratta: about. 2013. [Cited 30 Apr 2013]. Available from URL: http:// nhw.hume.org.au/about/ 18 Geelhoed GC, Klerk NH. Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Medical Journal of Australia 2012; 196: 122–126. 19 Aziz O, Athanasiou T, Tekkis PP et al. Laparoscopic versus open appendectomy in children: a meta-analysis. Annals of Surgery 2006; 243: 17–27. Epub 2005/12/24. 20 Martin IC. Who operates when? II: The national confidential enquiry into perioperative deaths 2003. Hospital Medicine (London) 2003; 65: 196–197. 21 Lovett BE, Katchburian MV. Emergency surgery: half a day does make a difference. Annals of the Royal College of Surgeons of England 1999; 81: 62–64.
© 2015 National Rural Health Alliance Inc.
Aust. J. Rural Health (2015) 23, 155–160
Original Research Waiting for definitive care: An analysis of elapsed time from decision to surgery or transfer in a rural centre Hannah Dobson, MBBS, BMedSc,1 Weranja K.B. Ranasinghe, MBChB, MRCSED,1 Matthew K.H. Hong, MBBS, BMedSc,1 Liliana N. Bray, BMedSc(Hons),1 Manivannan Sathveegarajah, MD, BSc,1 Fatima Vally, MBBS, BMedSc,1 and Francis J. Miller, MBBS, PhD, FRACS1,2 1
Department of Surgery, Northeast Health Wangaratta, Wangaratta and 2Rural Health Academic Centre, Melbourne University, Melbourne, Victoria, Australia
Abstract Objective: To examine the timing of operative management and interhospital transfer of emergency general surgical patients in a regional setting. Design: Retrospective cohort study. Setting: The surgical unit at a major rural referral centre for North-Eastern Victoria servicing a population of 90 000. Participants: General surgical patients (n = 649) admitted via the emergency department at Northeast Health Wangaratta between January 2011 and March 2013 undergoing operative management (n = 608) or transfer to a tertiary centre (n = 44). Main Outcome Measures: Timing of operative management, using appendicectomy as a benchmark operation, was measured as time from presentation to decision to operate, time from decision to surgery, percentage after-hours operating and length of stay (LOS). Time to interhospital transfer was calculated and reasons for delay were sought. Results: Two hundred forty-six appendicectomies were performed. Median time from decision to operate to theatre was 3 hours (interquartile range (IQR) 2–8), and total LOS was 43 hours (IQR: 28–56). Two hundred seventy-two procedures (43%) were performed out-ofhours, including 48% of appendicectomies. Median
Correspondence: Dr Hannah Dobson, Department of Surgery, Northeast Health Wangaratta, 35–47 Green Street Wangaratta, Victoria, 3677, Australia. Email: [email protected] Ethics Approval: IRB: Northeast Health Wangaratta Human Research Ethics Committee. Accepted for publication 23 September 2014. © 2015 National Rural Health Alliance Inc.
time from decision making to transfer was 10.3 hours (IQR: 4.7–25). Transfer was less likely to be delayed in trauma patients when compared with urgent nontrauma patients (5.3 versus 10.6 hours; P = 0.04). Conclusion: Even in the absence of a strict four-hour rule program and a dedicated emergency surgical unit, main outcome measures appear to be comparatively efficient. However, the duration for transfer of patients is suboptimal because of the lack of established pathways for urgent non-trauma transfer from rural centres and bed availability in tertiary hospitals. KEY WORDS: acute care surgery, emergency surgery, patient transfer, rural health service.
Introduction The ever-increasing medical complexity of patients and an ageing population have led to a growing demand for acute surgical interventions and substantial strain on health-care systems.1–6 Acute surgical care models and emergency general surgery (EGS) units have been developed with the aim of increasing consultant-led patient care, dedicated in-hours emergency theatre lists and improved surgeon satisfaction.1,3,6–9 These have led to reductions in time to definite operative management, as measured by benchmark emergency procedures such as appendicectomy, cholecystectomy and hip joint replacements for femoral fractures.6–8,10–13 However, many of these studies are based on data from metropolitan hospitals. The practice of rural surgery bears unique challenges compared to those faced in tertiary centres. Wider scopes of practice, reduced critical care support and logistical problems associated with large distances from major hospitals contribute to potential differences in outcomes for rural surgical patients. The provision of ‘definitive surgical care’ in a doi: 10.1111/ajr.12160
156
What is already known on this subject: • There is a growing demand for acute surgical interventions, which has resulted in substantial strain on health-care systems. • Acute surgical models and emergency surgical assessment units have been developed to improve timely delivery of surgical care. • Much of the research supporting these units is based on data from large metropolitan hospitals, and the practice of rural surgery bears a number of unique challenges including wider scopes of practice and the need to transfer patients to tertiary centres.
rural centre thus entails a decision to operate urgently or transfer to a metropolitan centre for specialised care, a situation seldom encountered in the tertiary setting. Data from rural centres have generally been limited to subsets of patients, including major trauma or critically ill patients requiring transfer to intensive care units.14–16 This study presents the model of surgical care used at Northeast Health Wangaratta (NHW) and examines the timing of operative management and interhospital transfer of emergency general surgical patients. In addition, it examines the rate of after-hours operating in the absence of dedicated in-hours emergency operating lists.
H. DOBSON ET AL.
What this study adds: • This retrospective cohort study suggests that despite the absence of a strict four-hour rule program or dedicated emergency surgical unit, a rural surgical unit can manage emergency surgical conditions with at least comparable efficiency to metropolitan centres. • Resource allocation in rural surgical centres might be better focused towards development of pathways for urgent transfer of nontrauma, specifically with respect to bed availability in tertiary hospitals.
cal unit who required acute transfer to a tertiary centre for specialist care. Retrospective chart review was undertaken and data including age, gender, time of admission to the ED, hospital length of stay (LOS) and operative procedures were recorded. We defined an emergency general surgical procedure as any procedure required by a patient admitted to the general surgical unit following presentation to the ED. We excluded all patients with an unplanned return to theatre following an elective procedure. Further management at a tertiary centre was defined as patients requiring surgical or medical management unavailable at NHW. Medical records were unavailable for one patient.
Methods Patient population and surgical services NHW is a major referral health centre for NorthEastern Victoria, servicing a population of approximately 90 000 over 28 townships.17 The general surgical unit is staffed by four consultant surgeons, two registrars and two interns. The surgical on-call is run on a ‘consultant of the day’ model, and consultants cover one in four weekends. The hospital has 24-hour computed tomography availability and is able to provide 24-hour emergency surgery. There is no dedicated EGS unit and no operating theatre allocated exclusively for emergency surgery.
Data collection Following Human Research and Ethics Committee approval, we retrieved de-identified data from Health Information Services on all patients admitted via the NHW emergency department (ED) between 1 January 2011 and 31 March 2013 who required a surgical procedure or any patient admitted under the general surgi-
Timing of surgery or transfer In order to evaluate the performance of our emergency surgical service, we examined time from presentation to the ED to decision to operate, time to theatre, out-ofhours emergency theatre and hospital LOS.6,9 Appendicectomy was examined as a benchmark procedure for urgent surgery and an indicator of the emergency surgical workload to allow comparison with other models of surgical care.6,11,13 If patients received more than one operation during the admission, data were based on the initial procedure. For patients requiring interhospital transfer, we recorded time of admission, decision to transfer the patient and time of departure. We also recorded the mode of transportation. Patients were excluded if the time of decision to transfer could not be ascertained (n = 13). We defined a delay as any time for departure after decision for transfer was made beyond the minimum recorded transfer-out time of three hours. The reason for transfer was noted, and patients were separated into trauma and non-trauma groups. Where possible, the reason for any delay in transfer was recorded. © 2015 National Rural Health Alliance Inc.
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Types of surgery or transfer The study population was characterised by type of procedure. Procedures were classified according to whether they commenced during the day (0800–1700), the evening (1700–2200) or at night (2200–0800). We defined in-hours surgery as any procedure that commenced between 0800 and 1700, and out-of-hours surgery as any procedure commencing between 1700 and 0800.
Statistical analysis Data were reported as mean ± one standard deviation for normally distributed data or as medians and interquartile ranges (IQRs) where data were not normally distributed. The Student’s t-test was used to calculate the significance of difference between two means, while the Kruskal–Wallis test was used to determine the significance of difference between two medians. Analysis was performed with PASW Statistics 20.0 (formerly SPSS Inc, Chicago, IL, USA), and all tests were two sided with statistical significance assumed at P < 0.05.
Results Between January 2011 and March 2013, 634 patients were admitted via the ED requiring EGS or interhospital transfer, with four patients requiring surgery prior to transfer. Six hundred seven patients underwent 626 general surgical procedures. An average of 24 ± 6 emergency procedures were performed per month. Three hundred fifty-four patients (55.8%) were admitted in-hours. The average age of patients was 48 ± 25 years, with a range from 4 to 96 years.
Two hundred forty-four appendicectomies were performed (39%), with an average of 2.1 procedures performed per week. Of these, 221 (90.6%) were open procedures. Laparoscopic procedures were significantly biased towards female patients (22% male versus 78% female, P = 0.005).
Time to definitive surgery The overall median time to theatre was 12 hours (IQR: 4–25 hours) (Table 1). Of patients requiring appendicectomy, the median time from admission to theatre was nine hours (IQR: 4–19 hours). The time of decision to proceed to theatre was recorded in only 148 (60.7%) patients undergoing an appendiectomy. Of these cases, median time from presentation to the ED to the decision to operate was three hours (IQR: 1–12). Overall median hospital LOS was 49 hours (IQR: 28–129 hours) with median hospital LOS in patients requiring an appendiectomy of 43 hours (IQR: 28–56 hours). Two hundred sixty-six procedures (43.8%) were performed out-of-hours; 35 procedures (5.8) occurred at night. One hundred seventeen appendicectomies (48%) were performed after-hours, and nine (3.7%) occurred at night (Table 1).
Patients requiring transfer Thirty-one patients required transfer from NHW to a tertiary centre for definitive care (Table 2). The urgency for transfer differed among trauma patients from nonurgent single fractures to patients with multiple injuries. Similarly, non-trauma patients encompassed a range of
TABLE 1:
Outcomes of patients requiring an emergency general surgical procedure
Procedure
Total number
Time from ED to theatre Median (IQR), hours
Hospital LOS Median (IQR), hours
Post-op LOS Median (IQR), hours
Out-of-hours operating (%)
Nighttime operating (%)
Appendicectomy Adhesiolysis Bowel resection Cholecystectomy Oversew of perforation Abscess Hernia repair Other Endoscopic procedure Total
244 19 66 41 10 30 37 7 153 607
9 17 10 30 5 6 5 23 19 12
43 157 223 96 164 24 34 52 48 49
24 114 191 50 159 18 19 29 21 27
121 10 42 11 10 16 20 3 33 266
10 0 10 1 2 1 6 0 5 35
(4–19) (6–61) (6–28) (21–51) (3–8) (4–18) (3–8) (10–32) (5–40) (4–24)
(29–56) (98–227) (140–336) (72–167) (124–190) (21–46) (22–63) (48–93) (18–94) (27–119)
ED, emergency department; IQR, interquartile range; LOS, length of stay. © 2015 National Rural Health Alliance Inc.
(18–42) (82–166) (130–279) (41–122) (114–187) (14–27) (16–60) (17–83) (7–48) (18–94)
(49.6) (52.6) (63.6) (26.8) (100) (53.3) (54.1) (42.9) (21.6) (43.8)
(4.1) (0) (15.2) (2.4) (20) (3.3) (16.2) (0) (3.3) (5.8)
158 TABLE 2:
H. DOBSON ET AL.
Trauma versus non-trauma summary of transfers
Total number of patients Male Age (mean ± SD) Time from decision to transfer Median (IQR), hours
All patients requiring transfer
Trauma
Non-trauma
P-value
31 19 (61.3%) 49.3 ± 25.0 9.3 (4.6–20.4)
9 4 (44.4%) 36.7 ± 15.4 5.3 (3–8.0)
22 15 (68.2%) 54.5 ± 26.6 10.6 (5.9–23.7)
0.23 0.07 0.04
IQR, interquartile range; SD, standard deviation.
FIGURE 1: Timing of transfer: plot of times from decision making to transfer for trauma and non-trauma patients. Logarithmic scale used because of the long elapsed times seen in the nontrauma category. Median time for trauma patients (5.3 hours) was significantly less than that for non-trauma patients (10.6 hours), P = 0.04.
conditions including those requiring urgent intervention such as ischaemic limbs (n = 2, 9%), acute coronary syndromes in a surgical patient (n = 1, 5%), severe pancreatitis (n = 1, 5%) and septicaemia (n = 6, 27%). A median time of 9.3 hours (IQR: 4.6–20.4 hours) was noted from decision making to transfer out of the hospital, with delay commonly caused by lack of bed availability in the tertiary centre. Trauma patients were significantly less likely to experience such delays when compared with non-trauma patients (5.3 hours, IQR: 3–8.0 hours versus 10.6 hours, IQR: 5.9–23.7 hours; P = 0.04) (Fig. 1). Some urgent non-trauma conditions such as ischaemic limbs requiring vascular intervention were subjected to long transfer times including one of 26 hours.
Discussion The practice of rural surgery bears unique challenges to those faced in tertiary centres including wider scopes of practice, reduced critical care support and logistical problems associated with large distances from major hospitals. Our study has been limited to timing of care and did not examine complication rates. Hospital LOS was used as a surrogate marker of successful clinical management. The applicability of our data to other centres might be influenced by surgeon preference as demonstrated by a tendency to conservatively manage conditions such as acute cholecystitis and a penchant to
perform open appendicectomies. Additionally, the retrospective nature of the study is associated with inherent problems of incomplete documentation and recorder bias. Nevertheless, a comparison with data from larger centres highlights some advantages and disadvantages of rural surgery. Following the observation of increasing strain on health-care systems, the Four Hour Rule Program was implemented to combat ED overcrowding.18 With no strict implementation of the Four Hour Rule Program at NHW, the median time from ED admission to decision to operate for appendicitis was three hours and median time to theatre was nine hours. Cubas et al.10 reported a median time from hospital presentation to theatre of 11.0 hours. We performed a greater number of appendicectomies than Cubas et al.10 (average 1.7 appendicectomies per week versus 2.1 per week) and reported similar median hospital LOS (43.2 versus 43 hours). The majority of appendicectomies were open procedures, and this might have positively influenced our time to theatre. However, it has previously been documented that laparoscopic appendicectomy is associated with a comparable operative time.19 Our results suggest that, at least in a rural surgical setting similar to NHW, a model that allows patients to be prioritised and managed according to severity rather than according to their ED LOS can offer equal or better patient safety and quality of care compared to those reported in the literature. © 2015 National Rural Health Alliance Inc.
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In order to increase availability of daytime operative availability and meet caseload demands, hospitals can create capacity for emergency cases on elective lists, use evening and weekend theatre sessions for semi-urgent cases, and physically separate emergency and elective operating teams.1–6,9,20 However, it is recognised that it is not always possible to delay a procedure until the next morning. Following the introduction of EGS theatre sessions, McGlade et al.12 reported a reduction in time to theatre from 41.8 to 26.4 hours in patients requiring an acute cholecystectomy, and Lovett et al.21 documented a reduction in emergency cases occuring after-hours from 88% to 53%. NHW has the ability to perform 24-hour emergency surgery; however, it does not have rostered theatre staff for night nor a dedicated surgeon and surgical team for out-of-hours operating. The majority of nighttime operating at NHW was performed for urgent cases, as demonstrated with 121 appendectomies occurring out-of-hours and 4.1% at night. This highlights the importance and use of 24-hour emergency theatre availability and demonstrates the success of a rural surgical unit in the absence of dedicated EGS theatre sessions. Surgeon satisfaction might have significant bearing on the success of any surgical care model. It is possible that the high morale and willingness to readily transfer or accept care of patients among surgeons within the unit facilitates such an efficient use of theatre time. The analysis of patients undergoing interhospital transfer demonstrated potentially significant delays faced by rural patients unable to be managed by local services. Non-trauma patients experienced a median time from decision to transfer of 11 hours, whereas trauma patients had a median transfer time of five hours. Bed availability at the receiving hospital accounted for the majority of delays. While this demonstrates effectiveness of established trauma pathways, non-trauma surgical emergencies such as limb ischaemia requiring vascular intervention had transfer times of up to 26 hours, placing greater burden on rural surgical teams who must manage these patients without necessary equipment, subspecialty expertise or critical care support. Thus, more resources towards bed availability at tertiary centres is required to provide optimal surgical care for patients.
Conclusion Providing definitive care in a major rural surgical referral centre such as NHW involves unique challenges including the need for interhospital transfer. In the absence of a strict four-hour rule program or a dedicated EGS unit, critical factors such as time from presentation to theatre, nighttime operating and LOS appear to be comparatively efficient. An emphasis on management © 2015 National Rural Health Alliance Inc.
based on clinical severity rather than ED LOS contributes to the efficiency of the surgical unit at NHW. However, timely transfer of non-trauma surgical patients requiring specialist care appears to be limited by bed availability in receiving hospitals. Resource allocation in centres such as NHW might be better focused towards development of pathways for urgent transfer of non-trauma patients.
Acknowledgements There are no declarations by any author of competing interests, financial or otherwise.
References 1 Garland AM, Riskin DJ, Brundage SI et al. A county hospital surgical practice: a model for acute care surgery. American Journal of Surgery 2007; 194: 758–763, discussion 63–4. Epub 2007/11/17. 2 Garling P. Final report of the Special Commission of Inquiry: acute care services in NSW public hospitals, 2008. 3 Poole GH, Glyn T, Srinivasa S, Hill AG. Modular acute system for general surgery: hand over the operation, not the patient. ANZ Journal of Surgery 2012; 82: 156–160. 4 Rowe P, Lawrence W, Fellows E. The management of emergency surgical patients in a surgical assessment unit. Annals of the Royal College of Surgeons of England 2003; 85: 274–277. 5 Trompetas V, Sandison A, Saunders M, Gurjar S. Morning or afternoon emergency list? Effects on service provision and training. International Journal of Surgery 2009; 7: 28–30. 6 Williams D, Cronin C, McCarthy C et al. Good practice in emergency surgery: a literature review. Victoria: Performance, Acute Programs and Rural Health Branch, 2010. 7 Earley AS, Pryor JP, Kim PK et al. An acute care surgery model improves outcomes in patients with appendicitis. Annals of Surgery 2006; 244: 498–504. 8 Gandy RC, Truskett PG, Wong SW, Smith S, Bennett MH, Parasyn AD. Outcomes of appendicectomy in an acute care surgery model. Medical Journal of Australia 2010; 193: 281–284. 9 Parasyn AD, Truskett PG, Bennett M et al. Acute-care surgical service: a change in culture. ANZ Journal of Surgery 2009; 79: 12–18. 10 Cubas RF, Gomez NR, Rodriguez S, Wanis M, Sivanandam A, Garberoglio CA. Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: impact on timing and cost. Journal of the American College of Surgeons 2012; 215: 715–721. 11 Faiz O, Banerjee S, Tekkis P, Papagrigoriadis S, Rennie J, Leather A. We still need to operate at night! World Journal of Emergency Surgery 2007; 2: doi:10.1186/1749-7922-229. 12 McGlade DP, Watters DA, Stupart DA. Emergency surgery model improves outcomes for patients with acute cholecystitis. Medical Journal of Australia 2013; 198: 413.
160 13 Schuster KM, Davis KA, Rosenbaum SH. Emergency and urgent surgery. Medical Clinics of North America 2009; 93: 1131–1148. 14 Flabouris A, Hart GK, George C. Outcomes of patients admitted to tertiary intensive care units after interhospital transfer: comparison with patients admitted from emergency departments. Critical Care and Resuscitation 2008; 10: 97–105. 15 Flabouris A, Hart GK, Nicholls A. Patients admitted to Australian intensive care units: impact of remoteness and distance travelled on patient outcome. Critical Care and Resuscitation 2012; 14: 256–267. 16 Zalstein S, Danne P, Taylor D et al. The Victorian major trauma transfer study. Injury 2010; 41: 102– 109.
H. DOBSON ET AL.
17 NHW. Northeast Health Wangaratta: about. 2013. [Cited 30 Apr 2013]. Available from URL: http:// nhw.hume.org.au/about/ 18 Geelhoed GC, Klerk NH. Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Medical Journal of Australia 2012; 196: 122–126. 19 Aziz O, Athanasiou T, Tekkis PP et al. Laparoscopic versus open appendectomy in children: a meta-analysis. Annals of Surgery 2006; 243: 17–27. Epub 2005/12/24. 20 Martin IC. Who operates when? II: The national confidential enquiry into perioperative deaths 2003. Hospital Medicine (London) 2003; 65: 196–197. 21 Lovett BE, Katchburian MV. Emergency surgery: half a day does make a difference. Annals of the Royal College of Surgeons of England 1999; 81: 62–64.
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