Volume 194 - Issue 7
Outcomes of appendicectomy in an acute care surgery model
Authors: Simone L Geere, Ratna Aseervatham and David Grieve
Med J Aust 2011; 194 (7): 373-374. || doi: 10.5694/j.1326-5377.2011.tb03016.x
Published online: 4 April 2011
Published online: 4 April 2011
To the Editor: We would like to congratulate Gandy and colleagues on their recent article in which they assess outcomes and patient flow in an acute care surgery (ACS) model.1
We have also performed a retrospective historical control study that examined the effect of an ACS model on assessment time and time to operation for acute appendicitis. Our findings were presented in poster format at the Royal Australasian College of Surgeons Annual Scientific Congress in Perth in May 2010.2
We introduced an ACS model in 2007 at Nambour General Hospital, a 350-bed regional hospital on Queensland’s Sunshine Coast. Our model differs in certain details from the model used by Gandy and colleagues at Prince of Wales Hospital, but is similar in principle. The aim of the ACS model was to provide an in-house consultant surgeon to be more available and more directly involved in the care of emergency surgical patients. In our study, the outcome measures included time to assessment of the patient in the emergency department by the surgical registrar, and time to operation after this assessment.
We performed a retrospective chart audit of 569 patients who underwent emergency appendicectomy in the calendar years 2006 and 2008. The ACS model resulted in an increase in both time to assessment (198 minutes in 2006 compared with 263 minutes in 2008; P < 0.0001 [t test]) and time to operation (597 minutes in 2006 compared with 793 minutes in 2008; P < 0.0001 [t test]).
These results surprised us. Various explanations were postulated, including the trend of an expanding local and regional population on the Sunshine Coast placing a greater demand on the emergency theatre through the study period. Like us, Gandy and colleagues did not see a reduction in time to theatre and in fact “observed no significant change in time from presentation to arrival in theatre”. This was explained on the basis of “an increase in the number of patients treated conservatively overnight”.
We have reviewed our data and found a similar trend, with 35% of patients in 2006 and 54% in 2008 managed conservatively overnight. This may, to some extent, explain our surprising results.
Our appendicectomies in both historical control patients and those treated in the ACS model were all performed laparoscopically, thus removing one of the confounders experienced in the Prince of Wales Hospital data.
A comparison of these two sets of data emphasises the fact that to measure time to assessment and time to operation in isolation misses the important concept of reduction in complication rates, as successfully demonstrated by Gandy and colleagues1 (we did not record complication rates in our study).
This process of assessment could be taken a step further with a cost–benefit analysis looking at the presumed reduction in costs associated with the anticipated lower rate of complications resulting from the involvement of the consultant surgeon.
References
- Gandy RC, Truskett PG, Wong SW, et al. Outcomes of appendicectomy in an acute care surgery model. Med J Aust 2010; 193: 281-284. 0_CHDDGDDH
- Geere SL, Grieve DA, Aseervatham RL. The effectiveness of the surgical emergency team at Nambour Hospital in surgical assessment time and time to operation for acute appendicitis [abstract]. Abstract No. GS31P. In: Special Issue. Abstracts of the Royal Australasian College of Surgeons Annual Scientific Congress, 4-7 May 2010, Perth, Western Australia. ANZ J Surg 2010; 80 (1 Suppl): A36-A37. 0_i1095849