Acute Surgery – The Australian Perspective
Mary Langcake
Outline ACUTE SURGERY
The Australian Perspective
Mary Langcake FRACS
Director of Trauma
SESIH
OBJECTIVES
* What is the issue
* Why has it arisen
* What is being done in Australia
* Does it work
* Beneifts
* Problems
* Where to from here
WHAT IS THE ISSUE?
* "Acute" vs "Emergency"
* The provision of safe, timely acute surgical care in the public sector is
becoming increasingly difficult
WHY HAS IT ARISEN?
* Limitation of resources
* Unpredictability of access to theatres during the working day
* Cancellation of elective surgery
* Most Public hospitals staffed by VMOs
* Public/private divide
* Work/life balance
WHAT IS BEING DONE IN AUSTRALIA
* Acute Surgical Units - The Ideal
* Consultant led
* Timely decision-making
* Dedicated emergency theatres
* Supervision of surgical trainees
* Surgery occurring "In Hours"
* Division of elective and emergency work
THE REALITY
* POW
* 8 general surgeons
* 0800 - 1800 Mon - Fri
* On call out of hours
* 4 bed ASU
* Dedicated OR
NEPEAN
* On call 7pm - 7pm
* In house 0700 - 1900
* 7/7
* Sole responsibility to ASU
* 2 Regs, 2 RMOs
* Nurse practitioner
WESTMEAD
* Hybrid system
* 7pm - 7pm call
* Mon - Fri
* W/E on call but pts admitted to ASU
* In House 0730ish to 1900ish
* Sole responsibility to ASU?
* Reg, RMO, Intern
OTHERS
* John Hunter Hospital
* Royal Perth
* Royal Brisbane Hospital - commencing an ASU in two weeks
* Dubbo - "a shambles" - dissolved through lack of support from Administration
* Victoria - no plans to implement ASU
* SA - no hospitals with ASU
DOES IT WORK
* 2 publications from Australia
* Parasyn et al. - POW
* ANZ J Surg 79 920090 12- 18
* Details of the model
* "change of culture"
* improved utilisation of emergency theatre
* less out of hours operating
* admissions saved
DOES IT WORK
* BUT
* No casemix data to compare before and after implementation
* Saved admissions based on registrar logbook and ACS and Reg "estimations"
* No patient outcome data
DOES IT WORK
* Cox et al. ANZ J Surg 80 (2010) 419 - 424
* "Descriptive"
* Improved timing of assessment by surgical team
* Sig improvement in timing of operative Mx
* Greater trainee supervision
* Improved consultant working conditons
DOES IT WORK
* Neither paper addresses patient outcomes
* No comparison of casemix before or after
* No report of patient satisfaction
* No indication of consultant attendance in theatre
BENEFITS
* Improved, formalised patient handover has been proven elsewhere to improve
outcomes
* Verbal discussions with colleagues working with ASU system report improved
lifestyle
* able to handover patients avoiding call backs for emergency patients
PROBLEMS
PROBLEMS
* Consultant driven decision making should lead to reduced investigations but
neither paper addresses this
PROBLEMS
* Trauma has been "absorbed" into discussions of acute/emergency surgery
provision
* Trauma is considered core business for all surgeons and is managed by ASUs in
some hospitals
* Consultants change daily
* Overlooks need for specialised trauma services with dedicated leadership and
oversight of patients
* Trauma care is more than simply "can I open a belly"
WHERE TO FROM HERE
* Consultant involvement in clinical redesign is paramount to improve delivery
of both emergency and elective operating
* The ASUs represent examples of clinicians actively engaging models of care
aimed at improved patient experience
* Work/life balance is key to ensuring surgical workforce longevity - ASUs play
an important role
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Ministry of Health
