Abstract
Background
The acute surgical unit (ASU) is a novel model for the provision of emergency general surgery care. The ASU model was initially developed in New South Wales hospitals during 2005 and 2006. Several studies have analysed the effects on patient outcomes and timeliness of care for nontrauma patients presenting with acute general surgical conditions. The purpose of this study was to perform a meta-analysis to determine the efficacy of the ASU model compared with the traditional on-call model for specific conditions.
Methods
A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data were extracted from each study and used to calculate a pooled odd ratio (OR) and 95 % confidence interval (CI).
Results
The search identified 18 studies; appendectomy (n = 9), acute cholecystitis (n = 7), and small-bowel obstruction (SBO) (n = 2). In the appendectomy cohort, the proportion of appendicular perforation were similar in pre-ASU and ASU period (OR 1.02, 95 % CI 0.77–1.37, p = 0.13). The incidence of complications in the appendectomy cohort was significantly lower in the ASU group; 14.5 % pre-ASU and 10.9 % post-ASU (OR 1.649, 95 % CI 0.732–3.714, p = 0.009). The negative appendectomy rate was similar for the pre- and post-ASU groups (OR 1.07, 95 % CI 0.88–1.31, p = 0.83). Likewise the conversion rate to open surgery and total hospital stay were similar between the two groups. The proportion of night time operations reduced significantly in the ASU period (OR 1.9, 95 % CI 1.32–2.74, p = 0.001). In the acute cholecystitis cohort, the conversion rate to open surgery was significantly higher in the pre-ASU group (15.1 %) compared with the post-ASU group (7.5 %) (OR 1.879, 95 % CI 1.072–3.293, p = 0.04) The incidence of complications was higher in the pre-ASU (14 %) compared with the post-ASU (6.8 %) group (OR 2.231, 95 % CI 1.372–3.236, p = 0.03). The mean hospital stay was significantly lower in the ASU period (5.3 vs. 3.7 days, p = 0.0063). There was insufficient data available to analyse outcomes for SBO.
Conclusions
The ASU model provides a safe surgical environment for patients and is associated with a reduced complication rate for appendectomy and laparoscopic cholecystectomy for acute cholecystitis. There is a reduced conversion rate and a shorter length of stay for patients with acute cholecystitis. Overall, the ASU model has translated to better outcomes for patients presenting with acute general surgical conditions.
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References
Uranues S, Lamont E (2008) Acute care surgery: the European model. World J Surg 32:1605–1612. doi:10.1007/s00268-008-9501-4
Hoyt D, Kim H, Barrios C (2008) Acute care surgery: a new training and practice model in the United States. World J Surg 32:1630–1635. doi:10.1007/s00268-008-9576-y
Diaz JJ Jr, Miller RS, May AK et al (2007) Acute care surgery: a functioning program and fellowship training. Surgery 141:310–316
Parasyn AD, Truskett PG, Bennett M et al (2009) Acute-care surgical service: a change in culture. ANZ J Surg 79:12–18
Cox MR, Cook L, Dobson J et al (2010) Acute surgical unit: a new model of care. ANZ J Surg 80:419–424
Von Conrady D, Hamza S, Weber D et al (2010) The acute surgical unit: improving emergency care. ANZ J Surg 80:933–936
Poole GH, Glyn T, Srinivasa S et al (2012) Modular acute system for general surgery: hand over the operation, not the patient. ANZ J Surg 82:156–160
Hsee L, Devaud M, Middelberg L et al (2012) Acute Surgical Unit at Auckland City Hospital: a descriptive analysis. ANZ J Surg 82:588–591
Hsee L, Devaud M, Civil I (2012) Key performance indicators in an acute surgical unit: have we made an impact? World J Surg 36:2335–2340. doi:10.1007/s00268-012-1670-5
Spain DA, Miller FB (2005) Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg 190:212–217
Reilly PM, Schwab CW (2007) Acute care surgery: the academic hospital’s perspective. Surgery 141:299–301
Malangoni MA (2007) Acute care surgery: the general surgeon’s perspective. Surgery 141:324–326
Committee on Acute Care Surgery American Association for the Surgery of Trauma (2007) The acute care surgery curriculum. J Trauma Acute Care Surg 62:553–556
Austin MT, Diaz JJJ, Feurer ID et al (2005) Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma Acute Care Surg 58:906–910
Earley AS, Pryor JP, Kim PK et al (2006) An acute care surgery model improves outcomes in patients with appendicitis. Ann Surg 244:498–504
Ekeh AP, Monson B, Wozniak CJ et al (2008) Management of acute appendicitis by an acute care surgery service: is operative intervention timely? J Am Coll Surg 207:43–48
Cubas RF, Gomez NR, Rodriguez S et al (2012) Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: impact on timing and cost. J Am Coll Surg 215:715–721
Lau B, Difronzo LA (2011) An acute care surgery model improves timeliness of care and reduces hospital stay for patients with acute cholecystitis. Am Surg 77:1318–1321
Britt RC, Weireter LJ, Britt LD (2009) Initial implementation of an acute care surgery model: implications for timeliness of care. J Am Coll Surg 209:421–424
Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62:1006–1012
DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188
Higgins JP, Thompson SG, Deeks JJ et al (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560
Egger M, Smith GD, Schneider M et al (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315:629–634
Orwin R (1983) A fail-safe N for effect size in meta-analysis. J Educ Stat 8:157–159
Gandy RC, Truskett PG, Wong SW et al (2010) Outcomes of appendicectomy in an acute care surgery model. Med J Aust 193:281–284
Notley RG (1997) Unsupervised surgical training: surgical training teaches surgical method, surgical anatomy, and operative skills. BMJ 315:1307–1307
Lehane CW, Jootun RN, Bennett M et al (2010) Does an acute care surgical model improve the management and outcome of acute cholecystitis? ANZ J Surg 80:438–442
Pepingco L, Eslick GD, Cox MR (2012) The acute surgical unit as a novel model of care for patients presenting with acute cholecystitis. Med J Aust 196:509–510
Kiviluoto T, Siren J, Luukkonen P et al (1998) Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 351:321–325
Britt RC, Bouchard C, Weireter LJ et al (2010) Impact of acute care surgery on biliary disease. J Am Coll Surg 210:595–599
Sorelli PG, El-Masry NS, Dawson PM et al (2008) The dedicated emergency surgeon: towards consultant-based acute surgical admissions. Ann R Coll Surg Engl 90:104–108
Doeksen A, Tanis PJ, Vrouenraets BC et al (2007) Factors determining delay in relaparotomy for anastomotic leakage after colorectal resection. World J Gastroenterol 13:3721–3725
Aitken RJ, Thompson MR, Smith JAE et al (1999) Training in large bowel cancer surgery: observations from three prospective regional United Kingdom audits. BMJ 318:702–703
Qureshi A, Smith A, Wright F et al (2011) The impact of an acute care emergency surgical service on timely surgical decision-making and emergency department overcrowding. J Am Coll Surg 213:284–293
Faryniuk AM, Hochman DJ (2013) Effect of an acute care surgical service on the timeliness of care. Can J Surg 56:022911–022911
Brockman SF, Scott S, Guest GD et al (2013) Does an acute surgical model increase the rate of negative appendicectomy or perforated appendicitis? ANZ J Surg 83:744–747
Poh BR, Cashin P, Dubrava Z et al (2013) Impact of an acute care surgery model on appendicectomy outcomes. ANZ J Surg 83:735–738
Pillai S, Hsee L, Pun A et al (2013) Comparison of appendicectomy outcomes: acute surgical versus traditional pathway. ANZ J Surg 83:739–743
Mercer SJ, Knight JS, Toh SK et al (2004) Implementation of a specialist-led service for the management of acute gallstone disease. Br J Surg 91:504–508
Lien I, Wong SW, Malouf P et al (2012) Effect of handover on the outcomes of small bowel obstruction in an acute care surgery model. ANZ J Surg 17:1445–2197
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Nagaraja, V., Eslick, G.D. & Cox, M.R. The Acute Surgical Unit Model Verses the Traditional “On Call” Model: A Systematic Review and Meta-Analysis. World J Surg 38, 1381–1387 (2014). https://doi.org/10.1007/s00268-013-2447-1
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DOI: https://doi.org/10.1007/s00268-013-2447-1