J R Soc Med 2005;98:14-17
doi:10.1258/jrsm.98.1.14
© 2005 Royal Society of Medicine
The surgical assessment unit—effective strategy for improvement of the emergency surgical pathway?
M S Mohamed MS FRCS
G R Mufti MCh FRCS
Directorate of Surgery & Anaesthetics, Medway Maritime Hospital,
Windmill Road, Gillingham ME7 5NY, UK
Correspondence to: Mr G R Mufti E-mail:
gr.mufti-urology{at}medway.nhs.uk
 |
SUMMARY
|
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A special unit was set up in an associate teaching hospital
to provide a
fast-track route for the assessment of acute adult
surgical and urological
referrals. During an audit period of
eight weeks, this surgical assessment
unit had 550 referrals,
of which 196 (36%) came via the accident and emergency
(A&E)
department; the other 354 came directly from general practitioners
or
other hospital departments. Mondays, Tuesdays and Fridays were
the busiest
days of the week; 57% of all patients arrived between
8 am and 5 pm. 68% were
seen by a doctor within 1 hour of their
arrival. 68% were either discharged or
admitted to the main
surgical wards within 4 hours. The study showed that,
over the
course of a year, the surgical assessment unit might divert
some 2301
patients away from the A&E department. To achieve
this total it would need
to be open and appropriately staffed
24 hours a day. Such a unit offers a
strategy for limiting the
A&E workload and streamlining the assessment of
patients
with surgical and urological emergencies.
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INTRODUCTION
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The initial assessment of most patients referred to hospitals
with acute
surgical and urological conditions takes place in
accident and emergency
(A&E)
departments.
1,2
However, with
the numbers of patients presenting as emergencies increasing
by
up to 5% per
year,
3-5
these departments experience increasing
difficulty in coping with their
workload. An additional pressure
is the target for patients to spend no more
than 4 hours in
the A&E department. For non-surgical patients medical
assessment
units have proved their
worth,
6 and some
hospitals allocate
a special area of such units for general surgery emergency
patients.
7 However,
there is only one published report on a surgical assessment
unit
(SAU).
8
When considering the possible merits of an SAU at our hospital we found, in
a three-month audit, that the ratio of emergency to elective surgical
admissions within general surgery and urology was 1.5 to 1—confirming
the impression that emergencies form a major part of the workload in these two
specialties. Yet these patients are customarily tagged on to the elective
component of the workload and commonly encounter delays. We therefore devised
an SAU that would provide a fast-track route for adult (age 16 years and over)
emergency surgical and urological referrals, allowing rapid diagnosis and,
where appropriate, early access to operating theatres. This paper reports on a
prospective eight week audit of activity within the SAU.
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PATIENTS AND METHODS
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The SAU was created by the allocation of a bay on a general
surgical ward.
There are six trolleys on which patients can
be assessed, with a waiting area
for 6 more patients. The unit
is staffed 24 hours a day by at least one
registered nurse who
is trained in the care of surgical patients. The
registered
nurse is usually assisted by a nursing assistant/auxiliary.
Ancillary
and clerical support is provided during working hours and the
unit
has a computer link to the hospital intranet and laboratory
service. Unstable
patients in need of immediate resuscitation
and patients with blunt or
penetrating trauma are assessed in
the A&E department and are either
admitted to the main ward
or discharged without going through the SAU. As a
matter of
policy, assessment is undertaken in the SAU only after the case
has
been discussed by the referring clinical personnel, usually
a doctor, with the
middle-grade member of the on-call surgical
or urological team. Medical staff
timetables were reorganized
to ensure that members of the surgical team,
including consultants,
had no fixed elective commitments while on-call. In
addition
an operating theatre was made available during working hours
exclusively
for patients presenting acutely.
This study was undertaken on patients who attended the SAU during the eight
weeks between 15 November 2003 and 10 January 2004. In keeping with current
targets that limit patients' stay in A&E departments, we set a target
for maximum stay on the unit of 4 hours. To achieve this, a second target was
created stipulating that all patients were to be seen by a doctor within 1
hour of arrival in the SAU. Once the patients had been assessed and the
results of investigations were available, a decision was made by the
appropriate middle-grade doctor or consultant to admit to one of the surgical
wards or discharge the patient back to primary care. Children under the age of
16 years were admitted directly to a paediatric ward so were not included.
Data were collected prospectively on a specially designed proforma and later
logged onto a spreadsheet for subsequent analysis. Data collected included the
patient's demographic details, source of referral, presenting complaints,
date and time of referral, time of arrival in the SAU, time taken for the
patient to be seen by a member of the on-call team and total time the patient
spent in the SAU.
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RESULTS
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During the study period 550 patients were referred to the SAU,
281 (51%)
male. Their mean age was 51 years (range 16–93).
328 (59%) patients were
referred from general practitioners,
196 (36%) came from the A&E
department and 26 (5%) were
from other sources such as the surgical
outpatients department
and non-surgical specialties. Mondays, Tuesdays and
Fridays
were the busiest days, Saturdays and Sundays the least busy
(
Table 1).
Out of 543 patients for whom data were available, 424 (78%) were referred
to the surgical team on-call and the other 119 to the urology team on-call.
The distribution of presenting complaints within each specialty is shown in
Table 2. The interval between
referral and arrival in the unit was recorded in 536 patients; 432 (81%) of
these arrived within 2 hours of referral. Whilst most patients arrived between
8 am and 5 pm there was a steady flow throughout the 24 hours
(Figure 1).
All patients were initially assessed by a registered nurse within 5 minutes
of arrival in the SAU. The time that patients waited to see a doctor is shown
in Figure 2; in the 479
patients for whom this information was recorded, the median time was 45
minutes (interquartile range 20–80). 325 (68%) patients were seen within
1 hour of arrival. Of the 154 patients who waited for more than 1 hour to see
a doctor, 108 (70%) had arrived between 8 am and 5 pm. Mondays and Fridays
were the days when patients were most likely to wait more than 1 hour
(Table 1).
Figure 3 shows the time
patients spent in the SAU before admission to a ward or discharge home. Median
duration of stay was 3.25 hours (interquartile range 2.0–4.0). Of the
453 patients for whom the data were recorded 308 (68%) left the SAU within 4
hours of their arrival. Of the 145 patients whose stay extended beyond 4
hours, 109 (75%) arrived between 8 am and 5 pm. Mondays and Fridays were the
days on which patients were most likely to spend over 4 hours in the unit
(Table 1).
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DISCUSSION
|
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The most important finding, in terms of alleviating pressures
on the
A&E department, was that 64% of patients seen in
the SAU came from sources
other than the A&E department.
These patients would have had to be seen in
the A&E department
if there had been no SAU. Extrapolation of this figure
indicates
that, over the course of a year, the SAU would divert 2301 patients
away
from the busy A&E department. The results also indicate
that, to
cater for the wide range of ages of patients presenting
with the full range
and severity of acute surgical and urological
disease processes, the SAU
should ideally be staffed by qualified
persons 24 hours a day. We would add
that the concentration
of acute surgical and urological conditions in the SAU
provides
excellent educational opportunities for surgical trainees, medical
students
and nursing staff.
Our data revealed that 68% of patients were seen within 1 hour by a doctor
and a similar proportion of patients left the SAU within 4 hours of their
arrival. Clearly, we need to improve on this performance; however, there was
no conclusive proof that more than an hour's wait to see a doctor was a
reason why some patients spent more than 4 hours in the unit. Excessive waits
were experienced by surgical and urological patients in equal measure and
seemed not to be influenced by source of referral. Mondays and Fridays were
the days of longest waits, and part of the reason may be that these are the
busiest days for clinical support services such as the pathology laboratories
and imaging departments.
In conclusion, the SAU can divert a substantial number of patients from the
increasingly busy A&E department and provides a separate facility for
rapid assessment and management by senior surgical staff. However, the unit
ideally should be staffed 24 hours a day, with reorganization of staff
timetables to develop the concept of an 'emergency surgical team'
who have no elective commitments when oncall. The SAU then becomes the hub of
emergency surgical activity.
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Acknowledgments
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We thank all the consultant general surgeons and urologists
at Medway
Maritime Hospital for allowing us to collect data
on their patients, and the
nursing staff on the SAU for their
contributions to data collection.
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SUMMARY
INTRODUCTION
