Implementation of an acute care emergency surgical service: a cost analysis from the surgeon's perspective

Acute surgical emergencies represent some of the most common reasons for hospital admission. Acute care surgery (ACS) can be defined as the urgent assessment and treatment of nontrauma general surgical emergencies in adults, with the intention of optimally treating intra-abdominal surgical crises.1 This includes a diverse number of conditions, such as acute appendicitis, cholecystitis, diverticulitis, pancreatitis, bowel obstruction, intestinal ischemia, intra-abdominal sepsis, incarcerated or strangulated hernias and perforated viscus. Until recently, the most common delivery model for the care of these patients revolved around a surgeon who was required to manage all surgical emergencies for a 12- to 24-hour interval while concurrently working within the demands of a scheduled clinical practice. This system has multiple limitations: interference with and required time away from a busy “scheduled” subspecialty practice, providing emergency surgery coverage throughout the night with the high likelihood of still needing to engage in patient care during a busy “post-call” day, and a potential lack of coordinated and current academic expertise within the specific focus of ACS. In response to these limitations, the concept of ACS has recently evolved in Canada. The delivery of an ACS model requires a dedicated hospital-based service that provides comprehensive care for all general surgical emergencies over a defined period of time (usually 7-day intervals). The potential benefits of this approach to acute surgical care include predictable scheduling for busy surgeons, predictable administration of operating suite resources, improved patient access and potentially improved patient care. Overall cost savings can also be substantial because of a reduction in night-time operating and additional staffing requirements. Beginning in Halifax in 1997, a number of Canadian centres have naturally evolved into this model of providing emergent surgical care. As of 2011, there were 16 fully functioning ACS programs across Canada1,2. The Acute Care and Emergency Surgery Service (ACCESS) at Victoria Hospital in the London Health Sciences Centre (LHSC) was established in July 2010, when our Division of General Surgery recognized the growing need for organized emergency general surgery (EGS) coverage. Prior to the implementation of ACCESS, there was no structured system for performing EGS cases during the daytime. Emergency patients would usually have their operations in the evening or night, after the completion of a surgeon’s elective daytime caseload; alternatively, patients would stay in the hospital — sometimes for days — before a surgeon was able to perform an operation during the elective schedule. The goal of ACCESS, therefore, was to shift EGS night-time operating to the daytime, without necessarily increasing the overall general surgery operating volume. Establishing a separate service was justified provided that it had a defined scope of practice and would not materially affect the other divisions in the department of surgery. Unfortunately, the academic advancement of the ACS concept, and therefore evidence-based improvements in outcomes after emergency surgical care, has been historically limited by an inability to capture and synthesize even basic patient data. The ability to improve patient outcomes through evidence-based research is particularly crucial because the emergency care of surgical patients is the common denominator among all general surgeons. Furthermore, there has been a historical absence of a dedicated group willing to advocate for evidence-based improvements in the care of those with general surgical emergencies. Regardless of professional interests, clinical load or working environment, the list of general surgical emergencies is common to every general surgeon in Canada who participates in a call schedule. It also involves a patient cohort that is unique from subspecialty nonemergent patients from both a physiologic and surgical perspective. As a result, the emerging organization of ACS as a distinct entity is aimed at improving the care and experience of surgically ill patients in their most dire time of need. The purpose of this study was to evaluate the implementation of an ACS service in London, Ont., with attention to the volume and distribution of EGS cases, its economic viability on the basis of surgeon remuneration as well as its impact on hospital resources.