Effect of the acute general surgical unit: a regional perspective

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Acute surgical units are a new paradigm of general surgery that have gained favour in many centres throughout Australia and New Zealand. This concept involves the creation of a team responsible solely for emergency cases, ideally with dedicated theatre time and a clear handover process, in order to reduce operative delays and improve patient care compared to the previous model where consultants superimposed emergency cases onto their usual caseload.
The framework was introduced based on literature demonstrating that most ‘emergency’ surgeries can tolerate short delays with no effect on outcomes. For example, studies have indicated that perforation in appendicitis usually occurs before presentation and in an aggressive subgroup,1 that the fear of perforated appendicitis leading to infertility is unfounded4 and that no change in perforation rates were seen if operating only occurred during daylight hours.5 On the other hand, the 20% commonly quoted negative appendicectomy rate exposes patients to unnecessary risks and wastes resources, so taking time to properly assess patients before theatre is essential.6 Additionally, with multiple studies demonstrating the safety of acute cholecystectomies,9 and associated reductions in hospital stay, lower morbidity rates and decreased overall economic costs compared to delayed cholecystectomy,10 it is important that there is an opportunity to perform such procedures. Studies have also shown that operations outside of daylight hours can lead to errors through impairments in speed, accuracy and dexterity and can cause reductions in performance and concentration similar to that of consumption of alcohol.11
Despite many major tertiary hospitals adopting the acute surgical model in Australia and New Zealand and the theoretical benefits of such a model, the literature has been divided in the results. Reduction in length of stay was seen in two studies,13 both looking at cholecystectomies only. However, many more studies did not show any reduction.15 Reduction in time to theatre was inconsistent again, with two studies showing a reduction,14 one study showing an increase19 and two showing no difference.16 Reduction in after‐hours operating was the most promising, with several studies showing a significant reduction16 and others trends towards improvement.15 However, this was also challenging to interpret given the inconsistencies between the definitions of ‘after‐hours operating.’ These discrepancies indicate that the acute surgical model does not reliably alter these commonly measured outcomes, and has many inter‐hospital variations. Only two studies examined regional hospitals, one examining cholecystitis outcomes15 and one appendicitis outcomes,19 with neither progressing past the abstract stage. The only significant findings were a reduction in time to theatre in the cholecystitis study, and increase in time to theatre in the appendicitis cohort.
Bendigo Health is a large regional hospital that performs 11 000 operations annually and services the Loddon Mallee region, which has a population of 307 405 and covers 26% of the geographical area of Victoria, Australia.23 In March 2012, the Acute General Surgical Unit (AGSU) was established, consisting of a rotating consultant general surgeon, registrar, two junior medical staff and a dedicated nurse. A handover occurs at 08.00 hour, and consultants are on call for a 24‐h period. There is a dedicated emergency theatre each weekday, which is staffed with a complete surgical and anaesthetic team, however, this covers emergency cases from all specialties, not just from General Surgery.
A 2014 systematic review on acute surgical units within Australia and New Zealand called for further research to investigate their applicability in different health care systems.24 There is a paucity of literature on how the acute surgical unit functions in Australian regional hospitals, and we aimed to investigate how AGSU has affected surgical outcomes in Bendigo Hospital.
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