Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (22 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
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Simon Paterson-Brown
The management of emergency surgery has undergone huge changes over the last 5 years as both surgeons and hospital managers have finally recognised that it is not only a major part of ‘general surgery’, but also associated with a significant morbidity and mortality, accounting for a large part of hospital resources. The American College of Surgeons National Surgical Quality Improvement Project recently examined the results of emergency appendicectomy, cholecystectomy and colorectal resections in 95 hospitals between 2005 and 2008.
1
They found that the risk of severe morbidity or death was 3.7% in the 30 788 appendicectomies performed, 6.37% in the 5824 cholecystectomies and 41.56% in the 8990 colorectal resections. Interestingly, they also identified that in 7–10% of hospitals good or bad performance could be generalisable across the three procedures, suggesting that there are ‘best’ and ‘worse’ practices to be identified.
Reduced bed days and improvements in patient care are, not surprisingly, associated with earlier and better clinical decision-making, prompt and appropriate surgery, along with reductions in readmissions and later requirements for surgery. Until recently, many surgical units throughout the world continued their elective work in tandem with their on-call commitments and, as a result, getting timely surgical intervention on all but the sickest emergency patients was difficult, resulting in delayed operations, usually going on late into the night and often carried out by junior surgical trainees. However, over the last few years, due to a number of factors, this has all changed. The increased number of surgical admissions to many hospitals, associated with regional reorganisation of surgical services
2,
3
and the associated increase in workload,
4
the reduced experience of surgical trainees due to the reduction in junior doctors' hours and training period,
5
and the recognition that early assessment by experienced senior surgeons with timely surgical intervention,
6
preferably by someone with an interest in that condition, have led to a recognition that a radical change in the provision of acute general surgical services was required. The Association of Surgeons of Great Britain and Ireland (ASGBI) held a consensus meeting on the future of emergency general surgery in 2006, subsequently publishing their conclusions,
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which are summarised in
Box 5.1
. A subsequent survey of consultant surgeons in the UK by the ASGBI
8
reported that: only 55% considered they were able to care well for their emergency patients; the workload was increasing with junior support decreasing; only 19% had comprehensive interventional radiology service out of hours; 55% had inadequate access to an emergency theatre; current pressure within the NHS favoured elective over emergency work; many felt they could not argue the case for change at a local level; and many felt that helpful changes would include national standards of practice and of service delivery, proper theatre access, and increased separation of elective and emergency work.
Box 5.1
Summary of the conclusions of the consensus meeting of the Association of Surgeons of Great Britain and Ireland (ASGBI) in 2006 on emergency general surgery
7
There is evidence that there is wide variation in the quality of emergency general surgery (EGS).
EGS is a huge clinical service with approximately 1000 finished consultant episodes per 100 000 population per year.
All hospitals should have a named surgeon responsible for the clinical leadership of EGS.
Emergency admissions must have dedicated resources and senior surgical personnel readily available.
There must be a clear and identifiable separation of delivery of emergency and elective care.
Local circumstances will determine model of delivery.
Timely access to diagnostic services (particularly radiology) and emergency theatre should be provided.
The assessment, prioritisation and management of emergency general surgical patients should be the responsibility of accredited general surgeons.
An essential prerequisite for accreditation in general surgery is competence to manage unselected general surgical emergencies.
The largest component of EGS is GI surgery.
The emergency general surgeon should remain competent in trauma management.
Vascular surgery is undergoing significant changes and in future will probably not be involved in EGS.
Dedicated breast surgeons are unlikely to be involved in EGS in the future.
Surgeons managing EGS should be as committed to continuing medical education related to EGS in a manner equivalent to their elective surgical practice.
The care of emergency surgical patients should be delivered to equal standards as those accepted for elective surgical practice.
Separation of elective and emergency surgery
Where in the past the continuity of care for surgical patients was maintained by the ‘middle grade’ surgical team, current rotas are now primarily of a shift pattern where the maximum time worked per week is around 48 hours, and as a result consultants find they rarely work with the same trainees
9
and continuity of care is reduced.
10
One solution to this problem was the introduction of the ‘surgeon of the day’, first suggested in 1995,
11
and then fully implemented in Edinburgh, UK, as the ‘emergency team’ in 1997.
12
With this system, the whole surgical team (consultant and supporting junior staff) have no elective commitments for their time on call and, although unfortunately shift working remains essential in many countries due to restricted working hours, the same trainees take part in the emergency team for extended periods of time. Their subsequent attachment to elective activity then no longer suffers from the disruption associated with on-call shifts, a state of affairs that enhances both emergency and elective training opportunities. This ‘emergency team’ system, with various adaptations according to local requirements,
13
has now been adopted in many units throughout the UK and increasingly worldwide. Two recent publications from the Association of Surgeons of Great Britain and Ireland include descriptions on the different ways that individual hospitals and regions in the UK have changed their service in order to improve the provision of emergency surgical services.
14,
15
Box 5.2
provides recommendations published by the Royal College of Surgeons of England
16
for the separation of elective and emergency general surgery.
Box 5.2
Summary of recommendations for separation of emergency and elective surgical care
A physical separation of services, facilities and rotas works best, although a separate unit on the same site is preferable to a completely separate location.
The presence of senior surgeons for both elective and emergency work will enhance patient safety and the quality of care, and ensure that training opportunities are maximised.
The separation of emergency and elective surgical care can facilitate protected and concentrated training for junior surgeons providing consultants are available to supervise their work.
Creating an ‘emergency team’, linked with a ‘surgeon of the week’, is a good method of providing dedicated and supervised training in all aspects of emergency and elective care.
Separating emergency and elective services can prevent the admission of emergency patients (both medical and surgical) from disrupting planned activity and vica versa, thus minimising patient inconvenience and maximising productivity for the hospital. The success of this will largely depend on having sufficient beds and resources for each service.
Hospital-acquired infections can be reduced by the provision of protected elective wards and avoiding admissions from the emergency department and transfers from within/outside the hospital.
The improved use of IT (information technology) solutions can assist with separating workloads (for example, scheduling systems for appointments and theatres, telemedicine, picture archiving and communication systems, etc.), although it is recognised that developments in IT for the NHS are generally behind schedule.
High-volume specialities are particularly suited to separating two strands of work. Other specialities can also benefit by having emergencies seen by senior surgeons – this can help to reduce unnecessary admissions, deal with ward emergencies and facilitate rapid discharge.
Copyright The Royal College of Surgeons of England. Reproduced with permission. Separating emergency and elective surgical care: recommendations for practice, The Royal College of Surgeons of England, 2007 (
www.rcseng.ac.uk/rcseng/content/publications/docs/separating_emergency_and_elective.htm
).
The emergency team undoubtedly improves the ability of the consultant general surgeon, as well as the middle grade team, to provide safe and effective emergency care, but requires other conditions to be met if this is to be both efficient and cost-effective, not only in terms of lost elective activity for the consultant but also training opportunities for the surgical trainees. These include easy access to radiological imaging, a dedicated emergency operating theatre with full (and senior) anaesthetic support available 24 hours each day,
17
enough surgical admissions to make the system worthwhile, and a distinct and dedicated admission area for emergency patients to be assessed. This is particularly useful in the assessment of patients with equivocal clinical signs, such as in early appendicitis, where the value of ‘active observation’ with reassessment after 2–3 hours by the same surgeon, repeated thereafter as necessary, is well established.
18
Emergency general surgery should be provided by a team that is free of elective commitments. All emergency general surgical patients should be admitted to a single dedicated admission area within the hospital, where they can be assessed and reviewed by the admitting surgical team. This should be supported by easy access to an emergency operating theatre and appropriate and timely radiological investigations.
7,
16
Along with the recognition that emergency surgery deserves more attention and support has also come the recognition that specialist conditions are often better treated by surgeons with a particular interest and experience in that subspeciality. This has of course been recognised for some time in the elective performance of a number of surgical procedures, including oesophagectomy, gastrectomy, abdominal aortic aneurysm repair, lung lobectomy, cardiac surgery and colectomy,
19,
20
and although mainly thought to be related to hospital and surgeon volumes,
21
specialisation of the surgical team is also an important factor.
22
However, there are now data available to support similar improvements in patient outcomes for emergency conditions, such as acute gallstone disease
23,
24
and acute colorectal disorders.
25
This is not surprising considering the subspecialisation that has occurred in general surgery over the last decade,
26
with consultant surgeons now being expected to deal with surgical conditions in the emergency situation that they no longer see in their elective practice. Reports of the separation of upper and lower elective and emergency gastrointestinal (GI) services in one region of Scotland have been encouraging. Not only has there been a significant increase in the number of patients with acute gallstone problems undergoing the same admission laparoscopic cholecystectomy,
27
there have also been improvements in the management of perforated duodenal ulcers,
28
and acute diverticulitis where patients have a lower mortality and fewer stomas.
29
The challenge now is for all those surgeons involved in the development and provision of emergency surgical care to produce on-call rotas that allow, where possible, patients with specific subspeciality conditions to be treated and operated upon by surgeons with a specific interest in that area. This will undoubtedly involve reorganisation of regional emergency surgical services, bringing together a wider group of surgeons for the on-call rota, with the ability to provide both upper and lower GI cover. The political hurdles of closing some emergency services in some hospitals in order to provide these larger emergency surgical units in other hospitals must be overcome if the undoubted improvements in patient care associated with dedicated emergency surgical services delivered by surgical teams with appropriate subspeciality expertise are to be realised, while at the same time providing robust junior doctor rotas that comply with the appropriate working time directives.