As part of the introduction of the ACSS, there was consolidation of emergency surgery care in the city of Winnipeg. Several smaller hospitals no longer provided emergency surgical care, thus patients were referred to St. Boniface for surgical consultation, which explains the doubling of patient volume seen after the ACSS was created.
Time from triage to surgical consultation was unchanged throughout this study, representing consistent emergency practices throughout all 3 time periods.
Despite a doubling in patient volume, the time to response by the ACSS team was significantly faster, illustrating that with a dedicated service, requests for surgical consultations were answered more efficiently. Time from consultation to admission was unchanged, as assessment of a surgical patient necessitates time for a history and physical examination, but also for laboratory testing and imaging, which in our study required an average of 2 hours 30 minutes to complete (data not shown), partly owing to delays inherent in ancillary services. Although the time to assess patients was unchanged, the overall time the patient spent in the emergency department once the ACSS was involved decreased. Thus the ACSS immediately improved patient flow through the emergency department. It is important to note that at St. Boniface, surgical beds are separate from medical beds, and surgical beds are rarely an issue for direct admission. Data on whether other surgical services or elective operations were affected by the creation of the ACSS were not collected.
Time to operation was no different among the pre- and post-ACSS periods, but this must be taken in the context of a doubling of patient volume after the establishment of the ACSS. This is in contrast to the findings of some ACSS services, indicating that in the context of acute appendicitis, the presence of an in-house acute care surgeon significantly decreased the time to operation.6,9
When considering patients with acute cholecystitis, Lehane and colleagues8
reported that an ACSS model decreased the median time to surgery; however, Ekeh and colleagues7
found no improvement in time to surgery with the presentation of appendicitis in their ACSS model.
In the present study, 63%–69% of emergency surgical operations occurred outside of regular work hours (4 pm to 8 am), illustrating a restricted access to the operating room during regular daytime hours. Dedicated operating time during the day would have a direct impact on patient throughput and timeliness of care. Given resource restrictions, this was not possible for the ACSS at the time of our study. This is in direct contrast to findings of a study of an American ACSS model, which reported that in the year before implementation of an ACSS model, 55.4% of emergent procedures were performed during a regular workday between the hours of 7:30 am and 5:30 pm, and improved to 70% after implementation of their ACSS model.5
This is in stark contrast to our findings, suggesting that direct access to operating room resources would improve timeliness of care for surgical patients within the context of the ACSS.
There was no difference in total length of hospital stay when all diagnoses were considered, but our subgroup analysis including appendicitis and cholecystitis but excluding bowel obstruction demonstrated that the ACSS decreased the length of stay (1 d 23 h in period 3 v. 2 d 21 h in period 1). This result highlights the efficiency of a dedicated surgical team in the management of patient flow. Our findings of shorter hospital stay were echoed by Earley and colleagues6
and Lehane and colleagues8
when considering acute appendicitis and acute cholecystitis, respectively.
This was a retrospective study, thus a decrease in time intervals for the study patients did not come at the expense of other patients with alternate surgical diagnoses also seen by the ACSS during the study. In fact, the very acute surgical emergencies (e.g., perforated viscus, ischemic bowel, necrotizing fasciitis) that take priority during triaging were not included in our study. We felt that because these patients take priority, with the creation of ACSS, the timeliness of care for these individuals would have also been significantly improved.
Limitations of our study include a relatively small number of patients evaluated in each group (most certainly a reflection of the 3-month periods studied), perhaps leading to an inability to establish significance in many of the care time periods examined. Our study was limited to 3 diagnoses (appendicitis, cholecystitis and bowel obstruction) and did not consider the many other diagnoses managed by the ACSS, including perforated viscus, diverticulitis, ischemic colitis and acute general surgical diagnoses. Whether the efficiency observed after the introduction of the ACSS exists within the context of these other disease processes is unknown, and we can only extrapolate based on the disease processes studied.
It was also impossible to evaluate whether other emergent surgical cases, such as perforated viscus, superseded or “bumped” surgery for patients with appendicitis, cholecystitis or bowel obstruction, thereby delaying the time to surgical intervention in our study.
The inclusion of bowel obstruction has affected our ability to truly evaluate both the time to operation and total length of hospital stay, as the treatment of obstruction usually commences with a trial of conservative management, thus naturally lengthening these time intervals. In retrospect, perhaps this diagnosis should not have been included. Future studies include staff and resident satisfaction and perceived efficiency of the ACSS.