Acute Care Surgery Models Worldwide: A Systematic Review

Wee, Mats J. L. van der; Wilden, Gwendolyn van der; Hoencamp, Rigo

doi:10.1007/s00268-020-05536-9

Cited by 22 publications

(13 citation statements)

References 84 publications

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“…The idea of streaming, although not always identified as such, underpins diverse healthcare interventions: separation of emergency from elective general surgery, 31 direct-entry subacute care, 32 risk-stratified chronic disease management, 33 stepped care for mental health, 34 and so on. Our specific findings may not apply to other interventions, some of which serve easily defined groups; deliver care virtually (not requiring designated physical space); or stream patients to facilitate ongoing targeted care, not rapid discharge.…”

Section: Original Researchmentioning

confidence: 99%

Realist analysis of streaming interventions in emergency departments

Anwar

Rowe

Metge

et al. 2021

leader

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BackgroundSeveral of the many emergency department (ED) interventions intended to address the complex problem of (over)crowding are based on the principle of streaming: directing different groups of patients to different processes of care. Although the theoretical basis of streaming is robust, evidence on the effectiveness of these interventions remains inconclusive.MethodsThis qualitative research, grounded in the population-capacity-process model, sought to determine how, why and under what conditions streaming interventions may be effective. Data came from a broader study exploring patient flow strategies across Western Canada through in-depth interviews with managers at all levels. We undertook realist analysis of interview data from the 98 participants who discussed relevant interventions (fast-track/minor treatment areas, rapid assessment zones, diverse short-stay units), focusing on their explanations of initiatives’ perceived outcomes.ResultsEssential features of streaming interventions included separation of designated populations (population), provision of dedicated space and resources (capacity) and rapid cycle time (process). These features supported key mechanisms of impact: patients wait only for services they need; patient variability is reduced; lag time between steps is eliminated; and provider attitude change promotes prompt discharge. Conversely, reported failures usually involved neglect of one of these dimensions during intervention design and/or implementation. Participants also identified important contextual barriers to success, notably lack of outflow sites and demand outstripping capacity. Nonetheless, failure was more commonly attributed to intervention flaws than to context factors.ConclusionsWhile streaming interventions have the potential to reduce crowding, a theory-based intervention relies on its implementers’ adherence to the theory. Streaming interventions cannot be expected to yield the desired results if operationalised in a manner incongruent with the theory on which they are supposedly based.

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Section: Original Researchmentioning

confidence: 99%

Realist analysis of streaming interventions in emergency departments

Anwar

Rowe

Metge

et al. 2021

leader

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“…Additionally, during after hours, most institutions also provide in-house resident coverage and attending on-call service. 3 However, there are some key differences among ACS models around the world. More structural ACS services have been established in North America, Europe and Australasia, including independent subunits and acute care wards, whereas in low-income countries like Africa, comprehensive ACS models have not yet been implemented.…”

Section: Introductionmentioning

confidence: 99%

“…In the USA, ACS models operated by trauma surgeons cover both trauma and EGS cases, whereas in Canada, Europe, and Australasia, EGS services are provided only by general surgeons. 3 4 …”

Section: Introductionmentioning

confidence: 99%

Impact of acute care surgery model in aspects of patients with upper gastrointestinal hemorrhage: result from a single tertiary care center in Thailand

Laohathai¹,

Jaroensuk²,

Laohathai³

et al. 2021

Trauma Surg Acute Care Open

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BackgroundEven though an acute care surgery (ACS) model has been implemented worldwide, there are still relatively few studies on its efficacy in developing countries, which often have limited capacity and resources. To evaluate ACS efficacy in a developin country, we compared mortality rates and intervention timeliness at a tertiary care center in Thailand among patients with an upper gastrointestinal hemorrhage (UGIH).MethodsThis retrospective study compared two 24-month periods between pre-ACS and post-ACS implementations from July 1, 2014, to June 30, 2018. Medical records from consecutive patients with UGIH in the surgical department of Chonburi Hospital, Thailand, were reviewed. The primary outcome was UGIH mortality rate differences between pre-ACS and post-ACS implementations. Differences in complications rate, length of hospital stay (LOS), time to esophagogastroduodenoscopy (EGD) and proportion of patients undergoing esophagogastroduodenoscopy (%EGD) in the same admission were also analyzed using unpaired t-test and Fisher’s exact test. Baseline characteristic differences between the pre-ACS and post-ACS periods were controlled for in multiple linear and logistic regression models.ResultsA total of 421 patients were included (162 pre-ACS and 259 post-ACS). Results showed a mortality rate of 24% in post-ACS compared with 41% in pre-ACS period (p<0.001). Overall complications (38% vs 27%), LOS (6.4 days vs 5.6 days) and time to EGD (44 hours vs 25 hours) were also significantly reduced, whereas %EGD increased (70% vs 89%). After adjusting for covariates, patients in the post-ACS period had lower risk of death (OR 0.54, p=0.040), lower risk of developing respiratory complications (OR 0.52, p=0.036), higher chance of receiving EGD in the same admission (OR 2.94, p<0.001) and shortened time to EGD for 19 hours (p<0.001).DiscussionOur results provide evidence that ACS can be implemented to improve patient outcomes at medical centers in developing countries with limited resources.Level of evidenceTherapeutic/care management, level IV.

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“…1 Trauma and EGS patients treated at specialized trauma and newly established ACS centers have achieved superior clinical outcomes compared to patients treated in nonspecialized centers. [2][3][4][5] The COVID-19 pandemic has challenged health care systems and hospitals with an increased demand for both human and material resources and has presented a unique opportunity to test the performance of the ACS model during this nonsurgical catastrophic event. 6 During the COVID-19 surge in Boston from March to May 2020, the ACS service at an urban, tertiary, level I academic trauma center was assigned to continue coverage of all trauma, EGS, and SCC patients, with the added responsibility of taking care of critically ill nonsurgical patients including COVID-19 positive patients.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic

Bugaev

Hojman

Breeze

et al. 2020

The American Surgeon™

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Background The role of an acute care surgery (ACS) service during the COVID-19 pandemic is not well established. Methods A retrospective review of the ACS service performance in an urban tertiary academic medical center. The study was performed between January and May 2020. The demographics, clinical characteristics, and outcomes of patients treated by the ACS service 2 months prior to the COVID surge (pre-COVID group) and during the first 2 months of the COVID-19 pandemic (surge group) were compared. Results Trauma and emergency general surgery volumes decreased during the surge by 38% and 57%, respectively; but there was a 64% increase in critically ill patients. The proportion of patients in the Department of Surgery treated by the ACS service increased from 40% pre-COVID to 67% during the surge. The ACS service performed 32% and 57% of all surgical cases in the Department of Surgery during the pre-COVID and surge periods, respectively. The ACS service managed 23% of all critically ill patients in the institution during the surge. Critically ill patients with and without confirmed COVID-19 infection treated by ACS and non-ACS intensive care units during the surge did not differ in demographics, indicators of clinical severity, or hospital mortality:13.4% vs. 13.5% ( P = .99) for all critically ill patients; and 13.9% vs. 27.4% ( P = .12) for COVID-19 critically ill patients. Conclusion Acute care surgery is an “essential” service during the COVID-19 pandemic, capable of managing critically ill nonsurgical patients while maintaining the provision of trauma and emergent surgical services.

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Acute Care Surgery Models Worldwide: A Systematic Review

Cited by 22 publications

References 84 publications

Realist analysis of streaming interventions in emergency departments

Realist analysis of streaming interventions in emergency departments

Impact of acute care surgery model in aspects of patients with upper gastrointestinal hemorrhage: result from a single tertiary care center in Thailand

Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic

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