Organisation and quality improvement in emergency general surgery

Introduction

Emergency general surgery (EGS) is a core component of general surgical practice. The challenges of caring for such patients include time-sensitive conditions, additional morbidity and mortality commensurate with this particular patient population, frequent diagnostic uncertainty, unpredictability, and the irregular consumption of hospital resources. EGS patients are increasingly managed by a multidisciplinary emergency surgical team requiring appropriate resources. Given the importance of this patient population and the changes to practice in many settings, particularly larger referral and teaching hospitals, emergency and acute care surgery is now being recognised as a distinct specialty by many colleges, professional associations and hospitals. This advance recognises the reality of increasing subspecialisation and the move to provide dedicated care for this patient population, with the resultant growth of emergency and acute care surgery models of care delivery.

EGS services have been shown to improve the timeliness of care and reduce complications, yet postoperative morbidity is still very common. ^, Coordination of care, efficient application of resources, access to services and timely intervention are of paramount importance. A study from the USA of 421 476 patients who required EGS between 2008 and 2011 found that the seven most common emergency procedures (partial colectomy, small bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendicectomy and laparotomy) accounted for 80% of activity, 80% of mortality, 79% of morbidity and 80% of the costs of the EGS cohort.

The American College of Surgeons’ National Surgical Quality Improvement Project (ACS-NSQIP) examined the results of emergency appendicectomy, cholecystectomy and colorectal (CR) resections in 95 hospitals between 2005 and 2008. The risk of severe morbidity or death was 3.7% in the 30 788 appendicectomies performed, 6.37% in 5824 cholecystectomies and 41.56% in 8990 CR resections. High morbidity and mortality is particularly apparent when comparing high-, middle- and low-income countries: in the first GlobalSurg study evaluating outcomes following EGS, mortality was three times higher in low- than in high-income settings.

Given that earlier clinical decision-making and prompt and appropriate surgery reduces length of stay (LoS) and readmissions, improving efficiency is critical. The creation of a dedicated EGS service, separated completely from elective surgical care, has been recommended by a number of professional societies, including the Royal College of Surgeons of England ; it is now commonplace in North America, Europe and Australia. Where program certification exists, additional improvements in outcomes have been described.

The variation worldwide in operative experience for trainees in general surgery remains a concern. Providing a dedicated service through which trainees rotate allows for a more concrete and mentored approach to managing these complex conditions, with structured opportunities for training. This also promotes the early assessment of patients by senior surgeons interested and experienced in these conditions coupled with access to radiological investigations and operating theatres for timely surgical intervention. ^, The Association of Surgeons of Great Britain and Ireland (ASGBI) conducted a survey of UK consultant surgeons: 55% reported that although they were able to care well for their emergency patients, the workload was increasing while junior support was decreasing; only 19% had comprehensive interventional radiology service out of hours; and 55% felt they had inadequate access to an emergency operating theatre. The results are summarised in Box 3.1 . The ASGBI has established an Emergency General Surgery Advisory Board to look specifically at ways of improving the delivery of all aspects of EGS and supporting clinicians who provide this care.

Specialisation in emergency and acute care surgery

While appropriate support for EGS is critical to improving resources and timeliness of care, such conditions are often best treated by surgeons with a particular interest in and experience with them, and within a surgical team and hospital system organised for this purpose. This mirrors development in other specialty practices, e.g. the regional centralisation of specific high-risk operations. This move to consolidate practices and performance of high-risk operations such as oesophagectomy, gastrectomy, abdominal aortic aneurysm repair, lung lobectomy and colectomy reflects the generally accepted observations of the volume-outcome relationship. In addition to surgical volume, institutional and team specialisation also appears to be an important factor. Evidence now supports similar improvements in patient outcomes for EGS procedures such as acute gallstone disease, appendicitis, peptic ulcer disease and CR disorders. Given the move towards subspecialisation that has occurred in general surgery over the last several decades, dedicated emergency surgery teams lead by consultant surgeons may be best placed to manage such conditions.

In the USA and Canada, there is now a specialist association of Acute Care Surgery ( http://www.aast.org/AcuteCareSurgery ) that exists within the American Association for the Surgery of Trauma (AAST). This professional organisation is for surgeons specialising in the care of the injured and critically ill surgical patients, as well as for the organisation and management of EGS. Beyond general surgery, board certification by the American Board of Surgery is awarded in Surgical Critical Care and allows surgeons to manage and provide comprehensive care for surgical patients in the intensive care unit. The fellowship is one year long, with the option to engage in a second year of acute care surgery, typically as a junior faculty member with oversight and guidance provided by more experienced acute care and critical care surgeons. This service has been demonstrated to reduce hospital LoS, costs, and increase efficiency. In a study of 1363 emergency surgery patients comparing management between trauma and critical care-trained surgeons versus general surgeons and subspecialists, trauma and critical care-trained surgeons saw 61% of the patients, and while there was no difference in operative management between the two groups, patients cared for by trauma and critical care-trained surgeons spent significantly less time waiting for an operation (7 vs 13 hours). Patients with acute appendicitis and acute cholecystitis also had shorter hospital stay (2.5 vs 2.8 days), and lower emergency department costs ($822 vs $876).

There is, however, wide variation in how EGS services are organised and implemented. In structured interviews with leaders of acute care surgery in the USA, respondents noted variability in whether services included trauma, elective general surgery, scheduled operating room time, and the sharing of responsibilities with other specialist surgeons. Other variations included whether formal sign out was performed, prospective data collection and the use of evidence-based protocols. The biggest concern was that this service might become a ‘wastebasket for everything that happens at inconvenient times’.

Organisation of elective and emergency surgery care

Over the past decades, many large medical centres have rearranged services to separate emergency and elective general surgery, with the goal of providing a dedicated acute surgical team to provide continuity for these high-risk patients. This separation is typically provided in one of two ways: a ‘surgeon-of-the-day’ rota with a dedicated consultant on call without conflicting clinical duties, or an Acute Surgical Unit (ASU) where all emergency patients are managed by a single team, typically with oversight by a consultant providing Monday–Friday continuity. ASUs now exist to manage such patients throughout the USA, Australia, New Zealand, the UK and Asia. The division between teams performing elective and EGS creates a dedicated surgical unit typically consisting of a consultant, trainee surgeons and junior doctors who can assess, investigate and manage EGS patients efficiently ( Box 3.2 ). In comparison to a surgeon/general surgical team having simultaneous elective and emergency responsibilities, this achieves improved ED assessment times, earlier investigations, 24/7 access to an emergency operating theatre and greater familiarity with acute general surgical conditions.

There is evidence that the ASU approach reduces mortality and morbidity. The ACS-NSQIP data from the USA demonstrated a reduced 30-day mortality in EGS patients treated in hospitals with an ASU model for EGS, especially in patients undergoing intestinal resections (30-day mortality 8.5% in ASU hospitals compared with 11.6% for all patients). This evidence has been reproduced in Australia, with higher index admission operation rates, shorter LoS, and reduced morbidity in patients requiring acute cholecystectomy. Most Australian units have embraced the ASU model and the General Surgeon Association (GSA) published a 12-point plan for EGS. In Singapore, which has more recently introduced the ASU model, data further confirmed reduced LoS and mortality (reduction in mean LoS from 4.5 to 3.5 days and mortality from 1.9% to 0.9%).

The separation of elective and emergency services was adopted in many UK hospitals in the late 1990s and typically consists of the Emergency Surgical Consultant (ESC) rather than the ASU model more commonly observed elsewhere. The ASGBI published a joint document with CR and upper gastrointestinal (UGI) subspeciality associations in 2015, making clear recommendations for the management of EGS including many of the key tenets mentioned above.

While having a dedicated surgical team to manage EGS patients reduces mortality and morbidity, the organisation of services may include a surgical assessment unit (SAU) to facilitate assessment and admission, timely access to investigations (notably radiology), and a dedicated emergency operating theatre. Depending on the size of a hospital and the number of EGS patients, the details of this set-up may differ.

For example, the Edinburgh, UK, experience with consultant-staffed ‘hot’ clinics reduced the need for inpatient admissions (85.0% vs 78.2% vs 54.4% before, 4 weeks and 6 months after clinic introduction, respectively) and shorter mean inpatient admission (64 vs 49 hours). Such a clinic allows general practitioners to refer directly to a consultant surgeon for rapid assessment, a quicker review of patients with acute abdominal pain in the emergency department, and in-person senior review of patients sent home after hours. Such a clinic must have ready access to radiological investigations (ultrasound [US], computed tomography [CT] and magnetic resonance cholangiopancreatography [MRCP] as required), bed space for short-term observation and review, as well as nursing and trainee doctors’ support.