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Comparative Study
. 2006 Oct;244(4):498-504.
doi: 10.1097/01.sla.0000237756.86181.50.

An acute care surgery model improves outcomes in patients with appendicitis

Angela S Earley  1 , John P Pryor, Patrick K Kim, Joseph H Hedrick, Jibby E Kurichi, Amy C Minogue, Seema S Sonnad, Patrick M Reilly, C W Schwab
Affiliations
Comparative Study

An acute care surgery model improves outcomes in patients with appendicitis

Angela S Earley et al. Ann Surg. 2006 Oct.

Abstract

Objective: To compare outcomes of appendectomy in an Acute Care Surgery (ACS) model to that of a traditional home-call attending surgeon model.

Summary background data: Acute care surgery (ACS, a combination of trauma surgery, emergency surgery, and surgical critical care) has been proposed as a practice model for the future of general surgery. To date, there are few data regarding outcomes of surgical emergencies in the ACS model.

Methods: Between September 1999 and August 2002, surgical emergencies were staffed at the faculty level by either an in-house trauma/emergency surgeon (ACS model) or a non-trauma general surgeon taking home call (traditional [TRAD] model). Coverage alternated monthly. Other aspects of hospital care, including resident complement, remained unchanged. We retrospectively reviewed key time intervals (emergency department [ED] presentation to surgical consultation; surgical consultation to operation [OR]; and ED presentation to OR) and outcomes (rupture rate, negative appendectomy rate, complication rate, and hospital length of stay [LOS]) for patients treated in the ACS and TRAD models. Questions of interest were examined using chi tests for discrete variables and independent sample t test for comparison of means.

Results: During the study period, 294 appendectomies were performed. In-house ACS surgeons performed 167 procedures, and the home-call TRAD surgeons performed 127 procedures. No difference was found in the time from ED presentation to surgical consultation; however, the time interval from consultation to OR was significantly decreased in the ACS model (TRAD 7.6 hours vs. ACS 3.5 hours, P < 0.05). As a result, the total time from ED presentation to OR was significantly shorter in the ACS model (TRAD 14.0 hours vs. ACS 10.1 hour, P < 0.05). Rupture rates were decreased in the ACS model (TRAD 23.3% vs. ACS 12.3%, P < 0.05); negative appendectomy rates were similar. The complication rate in the ACS model was decreased (TRAD 17.4% vs. ACS 7.7%, P < 0.05), as was the hospital LOS (TRAD 3.5 days vs. ACS 2.3 days, P < 0.001).

Conclusions: In patients with acute appendicitis, the presence of an in-house acute care surgeon significantly decreased the time to operation, rupture rate, complication rate, and hospital length of stay. The ACS model appears to improve outcomes of acute appendicitis compared with a TRAD home-call model. This study supports the efficacy and efficiency of the ACS model in the management of surgical emergencies.

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Figures

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FIGURE 1. Timeline. Three time intervals were calculated for each patient: time from ED presentation until surgical consultation, time from surgical consultation until surgery, and total time from ED presentation until surgery. Process components that occurred during each time period are displayed. ED, emergency department.
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FIGURE 2. Timing of consults for in-house acute care surgeon model (ACS) and home-call traditional model (TRAD).
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FIGURE 3. Timing of operations for in-house acute care surgeon model (ACS) and home-call traditional model (TRAD).
See this image and copyright information in PMC

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