Subspecialty approach for the management of acute cholecystitis: an alternative to acute surgical unit model of care

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The concept of acute care surgery was first developed in the United States in response to a crisis in trauma and emergency general surgery and to improve the provision of emergency surgical care.1 Acute surgical conditions account for approximately one quarter of public hospital admissions in Australia and these patients are consistently the most acutely unwell, highest risk and account for significant morbidity, mortality and financial burden to healthcare systems.3
The acute surgical unit (ASU) was introduced in many hospitals across Australia around 2005 in the hope of reducing the burden of emergency surgical services on the Australian healthcare system. This model was developed independently from the acute care surgery model of care, but has some similarities. The structure of an ASU varies from hospital to hospital, however, the fundamental elements are (i) 24‐h service dedicated to management of acute surgical pathologies only; (ii) onsite consultant with no other competing commitments; and (iii) separate emergency and elective surgery lists.
Although some studies have shown that the ASU may lead to a decrease in time to surgery, length of stay and complication rate,5 improvement in patient outcomes has also been demonstrated by studies assessing the subspecialty approach.9 Particularly in an era where subspecialty management of complex elective pathologies has become the norm, it might be speculated that a surgeon's subspecialty experience may lead to improved outcomes for patients in a corresponding emergency setting.12
Our institution is a metropolitan teaching hospital and tertiary referral centre in Sydney with over 500 patient beds that has employed a subspecialty based approach for over a decade. The local catchment population is over 400 000 people and the tertiary referral catchment exceeds 1.2 million people. The subspecialty model involves direct patient admissions under the most appropriate surgical subspecialty team. Patients with acute cholecystitis and other upper gastrointestinal (UGI) pathology are admitted directly under the UGI surgery unit. This unit consists of four consultants (one available 24/7), two fellows (one available 24/7), an UGI registrar and two junior medical officers. After hours, two general surgical registrars are available to admit patients directly under the UGI unit.
This study aimed to assess the outcomes of the management of acute cholecystitis by a specialty UGI unit. Our hypothesis was that a subspecialty model of care could produce results comparable to the ASU model.
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