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Often, surgeons would be expected to continue a subspecialty elective practice the very next day after being on call. In Canada, there has been a new, grassroots effort to focus and consolidate emergency general surgery EGS onto dedicated services. Limited data has been reported on the overall case mix of these new EGS services, or about their varied structures, processes or outcomes. More research is needed on the acuity, complexity and diversity of EGS services and systems, and on the roles that these services play in supporting surgical rescue in acute care health systems.
This study attempts to capture a snapshot at a single point in time of the case mix and workflow of a typical day in emergency general surgery across Canada. We hypothesized that Canadian EGS services face highly acute, complex and diverse case mix and that service models have evolved in unique ways in response to their local contexts.
Shared insights about case mix and 33 service delivery will inform the next generation of developments in quality improvement and health system design. It was felt that such a study would create a strong foundation for future clinical and systems studies in EGS, characterize future participating sites, identify synergies and opportunities for collaboration, help to disseminate best practices, and serve as a gap analysis to identify new research directions.
Many members of the Committee are EGS site leaders, which was a strong advantage for study design, institutional review, and data acquisition. The protocol for this cross sectional study was approved by the ethics review board at the study lead site Vancouver General Hospital and then at each of the participating hospitals. Service Structure A survey of EGS service leaders was used to characterize the different services at each hospital.
They were also asked if all general and subspecialty surgeons participated, about the involvement of resident coverage, the inclusion of trauma patients, and the existence of a formalized handover process between surgeons at shift change. Fourteen hospitals across Canada participated.
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Study personnel embedded on the services, with supervision by site leaders, collected data prospectively. The following patients were included in the study: those currently admitted to the EGS service, new consults, and any off-service patients being following by the EGS service between the hours of Jan 10, to Jan 11, Off-service was defined as patients admitted to the hospital but not under the direct care of an EGS surgeon.
Trauma patients and patients discharged from the EGS service prior to Jan 10, were excluded. Data was collected by study personnel at each site under the supervision of the site lead co-authors of this paper , and the primary author or the site lead did data entry. All patients currently admitted to the service and new consults were captured. Patient demographic information such as age, sex, comorbidities and previous operations was collected.
All operative and procedural data was collected. Intraoperative and postoperative complications were also collected. Data was verified with the site leads individually, and all perceived discrepancies and questions were resolved in a second round of communication with all sites. Results Emergency General Surgery EGS services from 14 hospitals across 6 provinces in Canada participated in this study to document service processes, patient demographics, case diversity and management plans over a single hour period Figure 3. Case Mix On January 10, , a total of patients were seen across the 14 sites.
In addition to their responsibilities of evaluating new consults and admissions, the teams also rounded on patients previously under the care of their team. There was only 1 intraoperative complication across all sites. The mean age was Patients had a wide range of presenting complaints and final diagnoses that demonstrate the breadth of emergency general surgical conditions evaluated and managed by EGS teams.
Table The most common diagnoses were gall bladder disease When evaluating the mean days in hospital since admission, neoplasms, pancreatic disease and intestinal obstruction were the top conditions requiring longer average stays in hospital. Discussion EGS services are well established across Canada. This study is a unique snapshot of the complex care that is provided on an average day at 14 hospitals. To our knowledge, this is the first prospective, national study of Canadian EGS services, and, as such, provides a novel look at a large, complex, and resource intensive patient population for which limited reporting exists in the literature.
To accomplish these goals, it is apparent from the variation in models adopted at the 14 participating sites, that hospitals have created services structured to meet objectives set based on their local context. The number of surgeons within a department, diversity in the continuum of learners at a site, proximity of tertiary trauma care, and executive administration and financial support are a few potential factors that can impact the organization of an EGS service.
The unpredictable pace of emergency surgery has made protected OR time an important part of delivering timely and safe care, and our data suggests there remains a gap in providing allocated time to emergency general surgeons and autonomy in deciding how unused resources are assigned. Case Mix and Service Activity The majority of the studies in the EGS literature have focused on processes and outcomes for appendicitis and cholecystitis, which, while accounting for a significant part of the activity of 37 EGS services, do not necessarily reflect the breadth, intensity or resource consumption of modern EGS practice.
The study confirms that Canadian EGS services are constantly weighing indications for surgery, and often successfully applying non-operative strategies. These patients can often require several resource intensive days in hospital yet their care is not well-documented in the EGS literature. Studies such as ours highlight an opportunity for research that aims to understand and improve the processes and outcomes of care for non-operative EGS patients. The complexity of EGS may, in part, be reflected by the extent of comorbidities and the frequent need for critical care.
The fact that all of these patients had been considered for, or had actually undergone, major emergency operations, is evidence that EGS services routinely face the heavy responsibilities of assessment, diagnosis, resuscitation and preoperative optimization, operative intervention, and postoperative care along fast timelines for extremely vulnerable patients. This intersection of aggressive surgical care and extreme patient vulnerability is a daily reality on modern EGS services, and an opportunity for multicenter quality improvement, guideline development, and promotion of best practices.
There is an urgent need for the next generation of EGS research to explore this intersection more fully. It is an observational study that did not capture every hospital with or without a formalized EGS service mostly due to difficulty in identifying these services and engaging them 38 in a national study , and therefore could not provide a comprehensive view of Canadian EGS practice. However, despite its methodological limitations, the study was a proof of concept that it is possible to bring emerging EGS services and patient level insights into a national research network.
The rapid completion of this study has shown that national collaboration on research protocol development, coordination of multicenter ethics review board applications, development of data sharing agreements, and shared data analysis, interpretation, and reporting, are highly feasible. The implications of a national EGS research network are great. We have seen in this study that EGS patient populations are large, complex, and resource intensive, and that the structures and processes of EGS care are variable.
A national EGS research network will be able to share experiences and define best practices, and will serve as a forum to make these experiences and best practices more universal. The network has already defined a research and quality improvement roadmap, with the next series of studies underway. Future studies will focus on processes of care, complex operative care, determinants of complications and mortality, benchmarks of quality, and surgical education in EGS.
Ultimately, it is hoped that this work will lead to a national EGS database and research strategy dedicated to analyzing diversity in the Canadian EGS experience, and to optimizing structure, process and outcome of EGS service delivery. They are busy intake services for extremely vulnerable patients with a spectrum of complex and acutely life threatening conditions including abdominal sepsis, intestinal obstruction and cancer. They optimize perioperative and operative care along the rapid timelines of acutely time dependent surgical illnesses, and, where possible, they often deploy non-operative approaches as well.
They act as rescue services, supporting patient care on other services, and very frequently providing care in intensive care units. Hameed at Please choose appropriately.
However, the surgical literature demonstrates that delays in acute care can cause adverse outcomes and negatively affect the patient and their healthcare experience Effective strategies to measure the process of acute care surgery may open opportunities to improve performance and optimize surgical outcomes in complex and vulnerable surgical populations. William Edwards Deming revolutionized the manufacturing world and helped to transform Japanese automobile production when he introduced the concept of process mapping.
The pioneering work of Dr. Deming is epitomized by understanding and learning to manage variation. In his seminal work, he stratifies the concept of variation into common and special causes. Alternatively, special causes are new and unanticipated variables that cause variance, and these causes are defects within the system which necessitate improvement, for example, different physician management strategies to clinical presentations.
The method allows providers to notice the small steps prior to management and discharge, and identify areas of high variation and bottlenecks for future improvement. Ultimately, our study aims to use process mapping to deconstruct the surgical care of patients presenting to emergency general surgery EGS services with acute small bowel obstruction SBO.
To our knowledge, process mapping has not yet been applied in evaluating the delivery of Acute Care Surgery services. The difference in the mean age between operative and conservative management cohorts The interval between being seen by an emergency department physician and a consult being sent to the EGS team also experienced higher times and unpredictability.
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Patients booked as a E1, our highest priority and meaning they should arrive in the OR within an hour of booking, never arrived at the OR within the expected time limits. Length of stay and waiting times have become benchmarks of quantifying clinical outcomes, however, this study further stratifies the overall hospital experience into granular periods of time that represent the steps in the clinical management of SBO patients. In our study and hospital environment, a source of variation in the operative and conservative management strategies of bowel obstruction patients was during the time in the emergency department.
Delays in requesting clinical imaging led to increases in mean time and variability in initiating an EGS team consult. Additionally, these delays also led to downstream effects for the EGS team and their ability to assess the patient and make relevant clinical decisions about management and treatment. A strategy to improve flow in the emergency department would be to add pre-printed orders PPO that summarize the evidence-based steps of the initial workup of a suspected case of a SBO. Using the PPO, the emergency physician would be able to start several treatment options and order imaging and laboratory tests critical to management of bowel obstruction patients prior to general surgery consultation.
Another area of clinical variation was in getting our operatively managed cases to the OR. Although this is a well-established barrier affecting surgeons globally81, we found that most of the high-priority cases were not getting to the OR in the expected intervals due largely to capacity issues. However, the EGS service at our institution has protected OR time that can be used for urgent cases, and our findings show that this time was being used effectively.
The 55 protected time led to patients receiving their surgeries within the expected interval who may not have if it was not for the dedicated time set aside for the EGS teams. Our sample size for this finding is small, and reflects a need for further data collection and analysis. The importance of investigating flow and process intervals in patient care is an emerging field in the era of increasing health expenditure and increasing operative and non-operative complexity of patients.
This is the first time such robust data collection strategies have been applied to non-operative patients who are managed by surgical teams. Although there were initial errors that required correction through detailed chart reviews, the program did extend the realm of patients that can be studied to improve quality and safety. From our experience, we discovered that this data was not difficult to collect and eventually led to insights that build efficiencies in the system.
In the future, another practice that can be adopted to track patient care is the use of an electronic platform to document points of care in the patient's journey through the hospital system. With this platform, the general surgery service could have access to real-time data to monitor metrics and evaluate how new QI interventions are working within our system, while simultaneously flagging new areas for intervention.
Additionally, even time stamps recorded on the electronic health record for certain points of care were subject to reporting bias, i. Additionally, our results are specific to our site and should not be generalized to other institutions, however the concept could be easily applied to any other system. The population we investigated was specific to one condition and part of a pilot EQIP project at our hospital, resulting in a small sample size, particularly our operative group. Future work will be directed at 56 larger groups of surgical patients with the hope of minimizing missing data and generating areas of QI and monitoring, the next steps in the RISE process.
We hope our work inspires other centres to follow similar methodologies to discover areas of improvement for surgical patients. As surgeons, this represents an exciting time for us to be leaders in safer patient care. Our cohort small bowel obstruction patients are the first group, to our knowledge, to be analyzed using this method and we hope to expand to more emergency general surgery patients in the future. The emerging EGS literature has provided powerful evidence that EGS services improve processes and outcomes for selected diagnoses, and that they have non-clinical advantages as well, including enhancing surgical education, improving surgeon job satisfaction, and potentially for improving the cost effectiveness of emergency surgical care.
The Day in the Life study showed us that sophisticated EGS systems have blossomed across Canada, and that they care for complex surgical patients with rapidly responsive and comprehensive service structures that have evolved independently to suit local contexts. We have also seen that the case mix of EGS is broad and without well defined metrics of disease severity and outcomes, and that patients face high levels of comorbidity, suggesting that the impact of EGS conditions on health and health care systems is likely larger than might have been previously thought.
These studies have provided us with both an environmental scan of the current state of EGS, and an analysis of gaps in our understanding, and, perhaps, a roadmap for the next generation of EGS research. More detailed studies of the case mix, disease severity, impact of comorbidity, operative and non-operative interventions, patient outcomes including long term and patient reported outcomes are needed in order to identify strategies to further consolidate and advance gains made by the early implementation of EGS services.
Individual centers will undoubtedly do this, and we have shown that this work can be done on a larger scale, and with more expertise, in a national collaborative. Multicenter initiatives have the advantage of bringing greater methodological expertise to individual studies, and also of creating networks to disseminate research findings and best practices. One promising avenue for research and quality improvement is to define complex health care processes in microscopic detail, identifying process variations, and targeting these variations with specific refinements.
EGS, with varied and complex time dependent processes, with extremely high stakes with respect to patient outcomes and health care costs, is fertile ground for this type of research. With the current data from our SBO process mapping study, surgeons, emergency physicians and radiologists have begun to meet, for the first time, to address 58 bottlenecks and variations in care through the development of pre-printed orders and clinical practice guidelines. Unconventional ideas, such as having SBO consults initiated by radiology, have begun to emerge from more precise, data-driven insights about process.
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Canadian Journal of Surgery. Early mortality after hip fracture: Is delay before surgery important? J Bone Joint Surg Am ;— Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression.
Can J Anaesthesia ;— Risk of emergency admission while awaiting elective cholecystectomy. CMAJ ;— Initiating statistical process control to improve quality outcomes in colorectal surgery. Surgical Endoscopy ;29 12 — Her background includes content marketing, event planning, employee relations, and even a bit of accounting and IT troubleshooting. The common denominator, and her driving passion, has always been her love of reading, writing, and editing.
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