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15-08-2011 | Article

Acute surgical service reduces ED crowding, surgical decision time


Free abstract

MedWire News: Study findings show that implementing the Acute Care Emergency Surgical Service (ACCESS) in emergency departments (EDs) significantly reduces patient length of stay, surgical decision time, and overall ED crowding.

Lead study author Homer Tien (Sunnybrook Health Sciences Center, Toronto, Ontario, Canada) said: "In the past 5 years, there has been a groundswell of support in both Canada and the USA for establishment of these services for various reasons, such as the growing difficulty of treating acute surgical conditions and a decrease in operative trauma surgical cases."

Tien and team assessed the impact of implementing ACCESS over a 1-year period on surgical decision time and "time-to-stretcher," a measure of overall ED crowding, in a large academic hospital.

In the ACCESS model, general surgeons commit to being available for a 7-day period, and to lead a team of residents and medical students. In addition, two staff surgeons share on-call duty to cover a full week. Staff surgeons do not perform elective surgery, but devote themselves to being available to perform emergency operations or consultations.

The team on duty was briefed on ACCESS targets, including responding to any ED request for consultation within 30 minutes, and final decisions regarding patient disposition to be made within 2 hours of the consult request.

In total, 1448 patients were included pre-ACCESS and 1062 were studied post-ACCESS. The majority of patients were referred for appendicitis, diverticulitis, bowel obstruction, biliary diseases, or postoperative complications.

Approximately 66% of these patients had a Canadian Triage and Acuity Scale (CTAS) score of 3, indicating that they needed to be seen by a physician within 30 minutes, 90% of the time.

Implementing ACCESS was associated with a significant 15% reduction in surgical decision time, from 12.6 to 10.8 hours. Mean time-to-stretcher was also reduced by a significant 20%, from 1.5 to 1.2 hours.

Moreover, ED length of stay was significantly reduced post-ACCESS implementation. For example, patients with appendicitis showed a 30% decrease, from 17.0 to 11.8 hours. Analysis revealed that this reduction was a result of improved timeliness of general surgery consultation response and decision making.

However, no significant difference was seen in the time interval from registration to the ED physician assessment, taking an average 8 hours before a general consultation for appendicitis was requested.

Despite significant reductions in surgical decision time, no significant differences in patient outcomes occurred.

"Future efforts should focus on improving the accuracy of wait time data, expediting consul requests for surgical services by ED physicians, expediting diagnostic imaging, and providing more timely access to the operating room," conclude the authors in the Journal of the American College of Surgeons.

By Ingrid Grasmo