Improving the Efficiency of the Emergency General Surgical Service

Miss C WesternMr J W Faux

Mrs M FeldmanThe Royal Cornwall Hospital, Truro

Our Unit:

• Prior to 2007 :

– Emergency Surgical take run on a Consultant of the day model

– 8 consultants – 10-bed SRU– 4 Surgical inpatient wards

Change was needed

• Reduction in Junior doctors hours• Full shifts

Led to little continuity of care

Service development

• 2 further Consultants appointed• ‘Split week’ on-call model proposed

• Expansion of SRU to 27 beds– 4x 6-bedded bays– 3x side room– Ultrasound room

Principles:

Responsibility for patient care passing forward on Monday and Friday am

Allowing ongoing twice daily senior review for patients:

• Under observation• Unstable & in need of monitoring• Likely to be discharged within a short time

frame

If discharged, OP F/U

under care of transferring Consultant

Benefits

• Separation of elective and on-call services• Reduction in length of stay:

N.B throughout this time admissions increased by 12%

• Dr Foster analysis for the 12 months from October 2007: Actual LOS = 2.1 days < predicted

• Best figure country-wide• The next nearest being 1.7 days < predicted

• Average admissions = 16/day

• Each day reduction in LOS = 16 less beds occupied by Surgical patients

• Proved possible to close an inpatient ward, saving £1.2 million/yr

Discussion:

• Emergency patients account for > half surgical admissions & bed-days

• Early assessment by consultants & rapid access to imaging ↓ admission rates & length of stay 1,2

• Combining all these factors → significant cost-savings & improved continuity of care

Conclusion:

• A consultant-delivered on-call service is a financially favourable model of care, reducing length of stay and an opportunity to improve training

References:

1. Cochrane RA et al. Senior surgeons and radiologists should assess emergency patients on presentation: a prospective randomised controlled trial. J R Coll Surg Eng. 1998; 43(5):324-7.

2. Britt WC, Weireter LJ, Britt LD. Initial implementation of an acute care surgery model: implications for timeliness of care. J Am Coll Surg. 2009; 209(4):421-4.