Impact of Surgeon Specialization on Outcomes in Emergency Colorectal Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Colorectal emergencies represent a large proportion of acute general surgical workload and carry significant mortality. OBJECTIVE: Identify the influence of surgeon specialization on mortality and other outcomes in emergency colorectal surgery. DATA SOURCES: Systematic searches of Ovid MEDLINE, Ovid EMBASE, and Cochrane electronic databases were performed for studies published from 1 January 1990 to 27 August 2023. STUDY SELECTION: Studies were included investigating outcomes in emergency colorectal surgery for adults, comparing colorectal against non-colorectal surgeon specialization. Exclusion criteria were: (1) publications studying primarily pediatric populations; (2) studies incorporating patients who had undergone surgery prior to 1990; (3) studies only published in abstract form or non-English language. MAIN OUTCOME MEASURES: Primary outcomes were 30-day mortality and in-hospital mortality. Secondary outcomes were rates of anastomotic leak, reintervention, primary anastomosis, and laparoscopic approach. RESULTS: Of 7676 studies identified, 155 were selected for full-text review and 21 studies were included for quantitative analysis. Eleven studies showed improved 30-day (OR 0.64, 95% CI 0.60-0.68, p < 0.0001) and in hospital mortality (OR 0.66, 95% CI 0.49-0.89, p = 0.007) with colorectal specialization. There was a significantly higher rate of primary anastomosis (OR 2.95, 95% CI 2.02-4.31, p < 0.0001) and use of laparoscopic surgery (OR 2.38, 95% CI 1.42-4.00, p = 0.001) amongst specialized colorectal surgeons. Specialization was also associated with a significant reduction in any stoma formation (OR 0.52, 95% CI 0.28-0.98, p = 0.04). No significant difference was observed for anastomotic leak (OR 0.70, 95% CI 0.45-1.07, p = 0.10) or reintervention rates (OR 0.78, 95% CI 0.55-1.10, p = 0.16). LIMITATIONS: Heterogeneity exists within the included patient populations and definitions of colorectal specialization observed in different countries. CONCLUSIONS: Emergency colorectal surgery undertaken by specialized colorectal surgeons is associated with significantly improved post-operative mortality, lower rates of stoma formation and increased rates of primary anastomosis and minimally invasive surgery. PROSPERO REGISTRATION: CRD42022300541.

Opioid prescribing, pain, and hospital stay of general surgery patients with oxycodone allergies in South Australia.

BACKGROUND: The frequency of oxycodone adverse reactions, subsequent opioid prescription, effect on pain and patient care in general surgery patients are not well known. This study aimed to determine prevalence of documented oxycodone allergy and intolerances (independent variables) in a general surgical cohort, and association with prescribing other analgesics (particularly opioids), subjective pain scores, and length of hospital stay (dependent variables). METHODS: This retrospective cohort study included general surgery patients from two South Australian hospitals between April 2020 and March 2022. Multivariable logistic regression evaluated associations between previous oxycodone allergies and intolerances, prescription records, subjective pain scores, and length of hospital stay. RESULTS: Of 12 846 patients, 216 (1.7%) had oxycodone allergies, and 84 (0.7%) oxycodone intolerances. The 216 oxycodone allergy patients had lower odds of receiving oxycodone (OR 0.17, P < 0.001), higher odds of tramadol (OR 3.01, P < 0.001) and tapentadol (OR 2.87, P = 0.001), but 91 (42.3%) still received oxycodone and 19 (8.8%) morphine. The 84 with oxycodone intolerance patients had lower odds of receiving oxycodone (OR 0.23, P < 0.001), higher odds of fentanyl (OR 3.6, P < 0.001) and tramadol (OR 3.35, P < 0.001), but 42 (50%) still received oxycodone. Patients with oxycodone allergies and intolerances had higher odds of elevated subjective pain (OR 1.60, P = 0.013; OR 2.36, P = 0.002, respectively) and longer length of stay (OR 1.36, P = 0.038; OR 2.24, P = 0.002, respectively) than patients without these. CONCLUSIONS: General surgery patients with oxycodone allergies and intolerances are at greater risk of worse postoperative pain and longer length of stay, compared to patients without. Many still receive oxycodone, and other opioids that could cause cross-reactivity.

Surgery's Rosetta Stone: Natural language processing to predict discharge and readmission after general surgery.

BACKGROUND: This study aimed to examine the accuracy with which multiple natural language processing artificial intelligence models could predict discharge and readmissions after general surgery. METHODS: Natural language processing models were derived and validated to predict discharge within the next 48 hours and 7 days and readmission within 30 days (based on daily ward round notes and discharge summaries, respectively) for general surgery inpatients at 2 South Australian hospitals. Natural language processing models included logistic regression, artificial neural networks, and Bidirectional Encoder Representations from Transformers. RESULTS: For discharge prediction analyses, 14,690 admissions were included. For readmission prediction analyses, 12,457 patients were included. For prediction of discharge within 48 hours, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.86 and 0.86 for Bidirectional Encoder Representations from Transformers, 0.82 and 0.81 for logistic regression, and 0.82 and 0.81 for artificial neural networks. For prediction of discharge within 7 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.82 and 0.81 for Bidirectional Encoder Representations from Transformers, 0.75 and 0.72 for logistic regression, and 0.68 and 0.67 for artificial neural networks. For readmission prediction within 30 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.55 and 0.59 for Bidirectional Encoder Representations from Transformers and 0.77 and 0.62 for logistic regression. CONCLUSION: Modern natural language processing models, particularly Bidirectional Encoder Representations from Transformers, can effectively and accurately identify general surgery patients who will be discharged in the next 48 hours. However, these approaches are less capable of identifying general surgery patients who will be discharged within the next 7 days or who will experience readmission within 30 days of discharge.

Sociocultural and Demographic Factors Predict Readmissions for General Surgery Patients.

INTRODUCTION: Readmission is a poor outcome for both patients and healthcare systems. The association of certain sociocultural and demographic characteristics with likelihood of readmission is uncertain in general surgical patients. METHOD: A multi-centre retrospective cohort study of consecutive unique individuals who survived to discharge during general surgical admissions was conducted. Sociocultural and demographic variables were evaluated alongside clinical parameters (considered both as raw values and their proportion of change in the 1-2 days prior to admission) for their association with 7 and 30 days readmission using logistic regression. RESULTS: There were 12,701 individuals included, with 304 (2.4%) individuals readmitted within 7 days, and 921 (7.3%) readmitted within 30 days. When incorporating absolute values of clinical parameters in the model, age was the only variable significantly associated with 7-day readmission, and primary language and presence of religion were the only variables significantly associated with 30-day readmission. When incorporating change in clinical parameters between the 1-2 days prior to discharge, primary language and religion were predictive of 30-day readmission. When controlling for changes in clinical parameters, only higher comorbidity burden (represented by higher Charlson comorbidity index score) was associated with increased likelihood of 30-day readmission. CONCLUSIONS: Sociocultural and demographic patient factors such as primary language, presence of religion, age, and comorbidity burden predict the likelihood of 7 and 30-day hospital readmission after general surgery. These findings support early implementation a postoperative care model that integrates all biopsychosocial domains across multiple disciplines of healthcare.

Vital signs and medical emergency response (MER) activation predict in-hospital mortality in general surgery patients: a study of 15 969 admissions.

BACKGROUND: The applicability of the vital signs prompting medical emergency response (MER) activation has not previously been examined specifically in a large general surgical cohort. This study aimed to characterize the distribution, and predictive performance, of four vital signs selected based on Australian guidelines (oxygen saturation, respiratory rate, systolic blood pressure and heart rate); with those of the MER activation criteria. METHODS: A retrospective cohort study was conducted including patients admitted under general surgical services of two hospitals in South Australia over 2 years. Likelihood ratios for patients meeting MER activation criteria, or a vital sign in the most extreme 1% for general surgery inpatients (<0.5th percentile or > 99.5th percentile), were calculated to predict in-hospital mortality. RESULTS: 15 969 inpatient admissions were included comprising 2 254 617 total vital sign observations. The 0.5th and 99.5th centile for heart rate was 48 and 133, systolic blood pressure 85 and 184, respiratory rate 10 and 31, and oxygen saturations 89% and 100%, respectively. MER activation criteria with the highest positive likelihood ratio for in-hospital mortality were heart rate ≤ 39 (37.65, 95% CI 27.71-49.51), respiratory rate ≥ 31 (15.79, 95% CI 12.82-19.07), and respiratory rate ≤ 7 (10.53, 95% CI 6.79-14.84). These MER activation criteria likelihood ratios were similar to those derived when applying a threshold of the most extreme 1% of vital signs. CONCLUSIONS: This study demonstrated that vital signs within Australian guidelines, and escalation to MER activation, appropriately predict in-hospital mortality in a large cohort of patients admitted to general surgical services in South Australia.

The Adelaide Score: An artificial intelligence measure of readiness for discharge after general surgery.

BACKGROUND: This study aimed to examine the performance of machine learning algorithms for the prediction of discharge within 12 and 24 h to produce a measure of readiness for discharge after general surgery. METHODS: Consecutive general surgery patients at two tertiary hospitals, over a 2-year period, were included. Observation and laboratory parameter data were stratified into training, testing and validation datasets. Random forest, XGBoost and logistic regression models were evaluated. Each ward round note time was taken as a different event. Primary outcome was classification accuracy of the algorithmic model able to predict discharge within the next 12 h on the validation data set. RESULTS: 42 572 ward round note timings were included from 8826 general surgery patients. Discharge occurred within 12 h for 8800 times (20.7%), and within 24 h for 9885 (23.2%). For predicting discharge within 12 h, model classification accuracies for derivation and validation data sets were: 0.84 and 0.85 random forest, 0.84 and 0.83 XGBoost, 0.80 and 0.81 logistic regression. For predicting discharge within 24 h, model classification accuracies for derivation and validation data sets were: 0.83 and 0.84 random forest, 0.82 and 0.81 XGBoost, 0.78 and 0.79 logistic regression. Algorithms generated a continuous number between 0 and 1 (or 0 and 100), representing readiness for discharge after general surgery. CONCLUSIONS: A derived artificial intelligence measure (the Adelaide Score) successfully predicts discharge within the next 12 and 24 h in general surgery patients. This may be useful for both treating teams and allied health staff within surgical systems.

Splenic artery embolization improves outcomes and decreases the length of stay in hemodynamically stable blunt splenic injuries - A level 1 Australian Trauma centre experience.

BACKGROUND: Splenic injuries are the most common visceral injury following blunt abdominal trauma. Increasingly, non-operative management (NOM) and the use of adjunctive splenic angioembolization (ASE) is favoured over operative management (OM) for the hemodynamically stable patient. However, clinical predictors for successful NOM, particularly the role of ASE as an adjunct, remain poorly defined. This study aims to evaluate the outcomes of patients undergoing ASE vs NOM. METHODS: A retrospective clinical audit was performed of all patients admitted with blunt splenic injury (BSI) from January 2005 to January 2018 at the Royal Adelaide Hospital. The primary outcome was ASE or NOM failure rate. Secondary outcomes were grade of splenic injury, Injury Severity Score (ISS), length of hospital stay (LOS), and delayed OM or re-angioembolization rates. RESULTS: Of 208 patients with BSI, 60 (29%) underwent OM, 54 (26%) ASE, and 94 (45%) NOM only. Patients were predominantly male 165 (79%), with a median age of 33 (IQR 24-51) years. The median ISS was 29 (20-38). There was no difference in the overall success rates for each modality of primary management (48 (89%) ASE vs 77 (82%) NOM, p = 0.374), though patients managed with ASE were older (38 vs 30 years, p = 0.029), had higher grade of splenic injury (grade ≥ IV 42 (78%) vs 8 (8.5%), p<0.001), with increased rates of haemo-peritoneum (46 (85%) vs 51 (54%), p<0.001) and contrast blush (42 (78%) vs 2 (2%), p<0.001). However, for grade III splenic injury, patients managed with ASE had a trend towards better outcome with no failures when compared to the NOM group (0 (0%) vs 8 (35%), p = 0.070) with a significant reduction in LOS (7.2 vs 10.8 days, p = 0.042). Furthermore, the ASE group overall had a significantly shorter LOS compared to the NOM group (10.0 vs 16.0 days, p<0.001). CONCLUSION: ASE as an adjunct to NOM significantly reduces the length of stay in BSI patients and is most successful in managing AAST grade III injuries.

The acute surgical unit: An updated systematic review and meta-analysis.

OBJECTIVE: To systematically review comparative studies on the acute surgical unit (ASU) model. METHODS: Searches were performed of Cochrane, Embase, Medline and grey literature. Eligible articles were comparative studies of the Acute Surgical Unit (ASU) model published 01/01/2000-12/03/2020. Amongst patients with any diagnosis, primary outcomes were length of stay, after-hours operating, complications and cost. Secondary outcomes were time to surgical review, time to theatre, mortality and re-admission for patients with any diagnosis, and cholecystectomy during index admission for patients with biliary disease. Additional analyses were planned for specific cohorts, such as patients with appendicitis or cholecystitis. RESULTS: Searches returned 9,677 results from which 77 eligible publications were identified, representing 150,981 unique patients. Cohorts were adequately homogenous for meta-analysis of all outcomes except cost. For patients with any diagnosis, compared with the Traditional model, the introduction of an ASU model was associated with reduced length of stay (mean difference [MD] 0.68 days; 95% confidence interval [CI] 0.38-0.98), after-hours operating rates (odds ratio [OR] 0.56; 95% CI 0.46-0.69) and complications (OR 0.48, 95% CI 0.33-0.70). Regarding cost, two studies reported savings following ASU introduction, while one found no difference. Amongst secondary outcomes, for patients with any diagnosis, ASU commencement was associated with reduced time to surgical review, time to theatre and mortality. Re-admissions were unchanged. For patients with biliary disease, ASU establishment was associated with superior rates of index cholecystectomy. CONCLUSION: Compared to the Traditional structure, the ASU model is superior for most metrics. ASU introduction should be promoted in policy for widespread benefit.

A systematic review of dedicated models of care for emergency urological patients.

OBJECTIVE: To systematically evaluate the spectrum of models providing dedicated resources for emergency urological patients (EUPs). METHODS: A search of Cochrane, Embase, Medline and grey literature from January 1, 2000 to March 26, 2019 was performed using methods pre-published on PROSPERO. Reporting followed Preferred Reporting Items for Systematic Review and meta-analysis guidelines. Eligible studies were articles or abstracts published in English describing dedicated models of care for EUPs, which reported at least one secondary outcome. Studies were excluded if they examined pathways dedicated only to single presentations, such as torsion, or outpatient solutions, such as rapid access clinics. The primary outcome was the spectrum of models. Secondary outcomes were time-to-theatre, length of stay, complications and cost. RESULTS: Seven studies were identified, totalling 487 patients. Six studies were conference abstracts, while one study was of full-text length but published in grey literature. Four distinct models were described. These included consultant urologists allocated solely to the care of EUPs ("Acute Urological Unit") or dedicated registrars or operating theatres ("Hybrid structures"). In some services, EUPs bypassed emergency department assessment and were referred directly to urology ("Urological Assessment Unit") or were managed by other dedicated means. Allocating services to EUPs was associated with reduced time-to-theatre, length of stay and hospital cost, and improved supervision of junior medical staff. CONCLUSION: Multiple dedicated models of care exist for EUPs. Low-level evidence suggests these may improve outcomes for patients, staff and hospitals. Higher quality studies are required to explore patient outcomes and minimum requirements to establish these models.

Emergency general surgery models in Australia: a cross-sectional study.

Objective Emergency general surgery (EGS) patients experience superior outcomes when cared for within an acute surgical unit (ASU) model. EGS structures in most Australian hospitals remain unknown. This study aimed to describe the national spectrum of EGS models. Methods A cross-sectional study was performed of all Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). The primary outcome was the incidence of each EGS model. Secondary outcomes were the relationship of the EGS model to objective hospital variables, and qualitative reasons for the choice of model. Results Of the 120 eligible hospitals, 119 (99%) participated. Sixty-four hospitals reported using an ASU (28%) or hybrid EGS model (26%), whereas the remaining 55 (46%) used a traditional model. ASU implementation was significantly more common among hospitals of greater peer group, bed number, surgeon pool and trauma service sophistication. Leading drivers for ASU commencement were aims to improve patient care and decrease after-hours operating, whereas common barriers against uptake were insufficient EGS patient load or surgeon on-call pool. Conclusions ASU or hybrid models of care may be more widespread than currently reported. The introduction of such structures is heavily dependent on hospital and staff size, trauma subspecialisation and EGS patient throughput. What is known about the topic? Traditionally, general surgical staff were rostered to elective operating and clinic duties, with emergency patients managed on an ad hoc basis. An ASU model, with a surgeon dedicated to EGS patients, has been associated with superior outcomes. However, the Australian uptake of this model is unknown. What does this paper add? This study enrolled 119 of 120 (99%) Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). Uptake of the ASU or hybrid model was more widespread than expected, existing in 64 of 119 (54%) centres. Factors for and against ASU implementation were also assessed. What are the implications for practitioners? Hospitals considering implementing an ASU or hybrid model will be reassured by the common reports of improved patient outcomes and decreased after-hours operating. However, potential hospitals must assess the suitability of the ASU model to their surgeon pool and EGS patient load.

The importance of wearing a seatbelt correctly - A case report of blunt trauma causing complete shearing transection of the gastroduodenal junction.

INTRODUCTION: Global mortality as a result of road traffic accidents (RTA) has reduced significantly since mandatory implementation of seatbelts. Whilst seatbelt related injury, or "seatbelt syndrome," is a recognised phenomenon, unrestrained passengers have considerably worse survival outcomes. Improper positioning of seatbelts, as is discussed in the following case, can cause extensive injury. PRESENTATION OF CASE: Our patient is a 35-year-old female who was a restrained front seat passenger in a car vs. tree collision at 80 km/h. Her seat belt was worn with the shoulder strap under her left axilla. She sustained multiple injuries including complete transection of the gastroduodenal junction. In addition to this she had splenic, liver, transverse colonic, left lower rib and humeral injury. She underwent damage control laparotomy with splenectomy; re-look with gastrojejunostomy and transverse colonic resection with defunctioning ileostomy. She made a good recovery and was discharged after a 4 week admission. DISCUSSION: Improperly worn seatbelts redistribute decelerative forces to sensitive regions. A multidisciplinary approach is required to effectively manage complex multi-system trauma. In trauma the simplest reconstructive measures can be the most effective and minimise risk of further complications for the patient. CONCLUSION: Improperly worn seatbelts pose a significant risk to patients. A traumatic complete gastroduodenal transection can be effectively reconstructed with gastrojejunostomy anastomosis.

Patient Satisfaction in Emergency General Surgery: A Prospective Cross-Sectional Study.

BACKGROUND: The importance of the patient experience is increasingly being recognised. However, there is a dearth of studies regarding factors affecting patient-reported outcomes in emergency general surgery (EGS), including none from the Southern Hemisphere. We aim to prospectively assess factors associated with patient satisfaction in this setting. METHODS: In this prospective cross-sectional study, all consecutive adult patients admitted to an acute surgical unit over four weeks were invited to complete a validated Patient-Reported Experience Measures questionnaire. These were completed either in person when discharge was imminent or by telephone <4 weeks post-discharge. Responses were used to determine factors associated with overall patient satisfaction. RESULTS: From 146 eligible patients, 100 (68%) completed the questionnaire, with a mean overall satisfaction score of 8.3/10. On multivariate analyses, eight factors were significantly associated with increased overall satisfaction. Five of these were similar to those previously prescribed by other like studies, being patient age >50 years, sufficient analgesia, satisfaction with the level of senior medical staff, important questions answered by nurses and confidence in decisions made about treatment. Three identified factors were new: sufficient privacy in the emergency department, sufficient notice prior to discharge and feeling well looked after in hospital. CONCLUSIONS: Factors associated with patient satisfaction were identified at multiple points of the patient journey. While some of these have been reported in similar studies, most differed. Hospitals should assess factors valued by their EGS population prior to implementing initiatives to improve patient satisfaction.

Does emergency general surgery model affect staff satisfaction, training and working hours?

BACKGROUND: Few studies have assessed the relationship between different emergency general surgery models and staff satisfaction, operative experience or working hours. The Royal Australasian College of Surgeons recommends maximum on-call frequency of one-in-four for surgeons and registrars. METHODS: A cross-sectional study was conducted of all medium- to major-sized Australian public hospitals offering elective general surgery. At each site, an on-call general surgery registrar and senior surgeon were invited to participate. Primary outcomes were staff satisfaction and registrar-perceived operative exposure. Secondary outcomes were working hours. RESULTS: Among eligible hospitals, 119/120 (99%) were enrolled. Compared with traditional emergency general surgery models, hybrid or acute surgical unit models were associated with greater surgeon and registrar satisfaction on quantitative (P = 0.012) and qualitative measures. Registrar-perceived operating exposure was unaffected by emergency general surgery model. Longest duration on-duty was higher among traditional structures for both registrars (mean 22 versus 15 h; P = 0.0003) and surgeons (mean 59 versus 41 h; P = 0.020). On-call frequency greater than one-in-four was more common in traditional structures for registrars (51% versus 28%; P = 0.012) but not surgeons (6% versus 0%; P = 0.089). Data on average hours per day off-duty were obtained for registrars only, and were lower in traditional structures (13 versus 15 h; P = 0.00002). CONCLUSION: Hybrid or acute surgical unit models may improve staff satisfaction without sacrificing perceived operative exposure. While average maximum duration on-duty exceeded hazardous thresholds for surgeons regardless of model, unsafe working hours for registrars were more common in traditional structures. General surgical departments should review on-call rostering to optimize staff and patient safety.

Communication and management of incidental pathology in 1,214 consecutive appendicectomies; a cohort study.

BACKGROUND: Important incidental pathology requiring further action is commonly found during appendicectomy, macro- and microscopically. We aimed to determine whether the acute surgical unit (ASU) model improved the management and disclosure of these findings. METHODS: An ASU model was introduced at our institution on 01/08/2012. In this retrospective cohort study, all patients undergoing appendicectomy 2.5 years before (Traditional group) or after (ASU group) this date were compared. The primary outcomes were rates of appropriate management of the incidental findings, and communication of the findings to the patient and to their general practitioner (GP). RESULTS: 1,214 patients underwent emergency appendicectomy; 465 in the Traditional group and 749 in the ASU group. 80 (6.6%) patients (25 and 55 in each respective period) had important incidental findings. There were 24 patients with benign polyps, 15 with neuro-endocrine tumour, 11 with endometriosis, 8 with pelvic inflammatory disease, 8 Enterobius vermicularis infection, 7 with low grade mucinous cystadenoma, 3 with inflammatory bowel disease, 2 with diverticulitis, 2 with tubo-ovarian mass, 1 with secondary appendiceal malignancy and none with primary appendiceal adenocarcinoma. One patient had dual pathologies. There was no difference between the Traditional and ASU group with regards to communication of the findings to the patient (p = 0.44) and their GP (p = 0.27), and there was no difference in the rates of appropriate management (p = 0.21). CONCLUSION: The introduction of an ASU model did not change rates of surgeon-to-patient and surgeon-to-GP communication nor affect rates of appropriate management of important incidental pathology during appendectomy.

Lessons learned from relocating an acute surgical unit to a new quaternary referral centre in Adelaide, South Australia: a tale of two hospitals.

BACKGROUND: On 4 September 2017, patient care was relocated from one quaternary hospital that was closing, to another proximate greenfield site in Adelaide, Australia, this becoming the new Royal Adelaide Hospital. There are currently no data to inform how best to transition hospitals. We conducted a 12-week prospective study of admissions under our acute surgical unit to determine the impact on our key performance indicators. We detail our results and describe compensatory measures deployed around the move. METHODS: Using a standard proforma, data were collected on key performance indicators for acute surgical unit patients referred by the emergency department (ED). This was supplemented by data obtained from operative management software and coding data from medical records to build a database for analysis. RESULTS: Five hundred and eight patients were admitted during the study period. Significant delays were seen in times to surgical referral, surgical review and leaving the ED. Closely comparable was time spent in the surgical suite. Uptake of the Ambulatory Care Pathway fell by 67% and the Rapid Access Clinic by 46%. Overall mortality and patient length of stay were not affected. CONCLUSION: We found the interface with ED was most affected. Staff encountered difficulties familiarizing with a new environment and an anecdotally high number of ED presentations. Delays to referral and surgical review resulted in extended patient stay in ED. Once in theatre, care was comparable pre- and post-transition. This was likely from early identification of patients requiring an emergency operation, close consultant surgeon involvement and robust working relationships between surgeons, anaesthetists and nurses.

Acute surgical unit improves outcomes in appendicectomy.

BACKGROUND: Few large Australian studies have explored the impact of acute surgical unit (ASU) model in appendicitis. METHODS: An ASU model commenced practice at our institution on 1 August 2012. In this retrospective cohort study, patients undergoing appendicectomy 2.5 years before (Traditional group) or after (ASU group) this date were compared. Primary outcomes were median length of stay, median time from emergency department referral to theatre start and proportion of cases performed in-hours. Secondary outcomes were rates of complications, open appendicectomy, consultant scrubbed for procedure, intensive care unit admission and re-presentation to emergency department within 30 days. RESULTS: After removing those with incomplete data, 1214 patients were enrolled; 465 in the Traditional group and 749 in the ASU group. There were no significant baseline differences between groups. Compared with the Traditional group, ASU patients had similar length of stay (1.81 versus 1.81 days; P = 0.54) and time to theatre (0.59 versus 0.56 days; P = 0.14), but a greater proportion of in-hours operation (72% versus 79%; P = 0.014). The ASU group also experienced fewer complications (9% versus 6%; P = 0.031), fewer primary open (4% versus 1%; P < 0.0001) or conversion-to-open appendicectomies (6% versus 2%; P < 0.0005) and had superior rates of consultant scrubbed in theatre (21% versus 56%; P < 0.00001). Rates of intensive care unit admission (1% versus 1%; P = 0.72) and re-presentation were unchanged (5% versus 5%; P = 0.46). CONCLUSION: In our institution, the introduction of an ASU model was associated with more in-hours operations and safer care for patients undergoing appendicectomy.

Non-operative management of isolated single abdominal stab wound: is it safe?

BACKGROUND: This is a retrospective review of prospectively collected data on our hospital, a Level 1 trauma centre, where stable patients with single abdominal stab wounds are considered for non-operative (conservative) management if they fulfil the criteria with the aid of computed tomography. The aim is to review our current approach in managing these patients. METHODS: Patients' data were obtained from January 2005 to June 2016. All injuries classed as assault or self-harm by sharp object in Injury Severity Score body region 4 were included. Patients were excluded from this study if they had haemodynamic instability, peritonism, significant findings on computed tomography, intoxicated, sustained head injury, sedated and intubated or evisceration of bowel, impalement of the stabbed object, potential thoraco-abdominal injury and multiple stab wounds. The patients were divided into non-operative and delayed operative groups for analysis. RESULTS: One hundred and sixty-six of the 313 patients who presented with abdominal stab wounds matched our criteria. One hundred and sixty-three patients (98.2%) from the non-operative group were discharged without complications following period of observation, while three patients underwent operative intervention following trial of non-operative management. The mean length of stay for the successful non-operative group and the group which required delayed operative intervention were 2.8 and 6 days, respectively. No morbidity or mortality was recorded in either group. CONCLUSION: Our observational study showed that in a Level 1 trauma centre, patients with single anterior abdominal stab wound and normal vital signs can potentially be safely managed with non-operative approach provided that these patients are cooperative for close observation.