New networks for emergency surgery proposed

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A new networked approach for emergency surgical care which, it says, would deliver a higher quality service to patients, preserve access across the country to senior surgical decision-makers, and create a working environment that was optimal for training, recruitment and retention of staff, has been proposed by the Royal College of Surgeons in Ireland. 

The Surgery for Ireland report, launched at the College’s annual Charter Day meeting, set out a series of recommendations, which it said, aimed at ensuring equitable regional access to higher-quality emergency surgical services,  while ensuring smoother transitions of care for people who required complex emergency surgery.

The RCSI said while most hospitals in Ireland provided emergency surgical care, current arrangements resulted in significant variation between hospitals in roster intensity, admission volume and operative complexity, with all hospitals having a significant reliance on locum staff. There were challenges in emergency access to specialist surgery and a lack of clarity among surgical trainees about their career trajectory and responsibilities.

The report proposed that Acute Surgical Assessment Units should be available in every hospital receiving surgical emergencies, to streamline surgical assessment and treatment and to allow a reduction in the number of hospitals providing out-of-hours emergency general surgery.

It recommended that geographically-based surgery networks be developed with agreed pathways to allow safe and efficient escalation of care in situations where a patient’s needs exceeded the services available locally and to support repatriation when patients needs could be met closer to home.

Optimal staffing of these emergency surgery networks should ensure that every staff member contributed to the extent of their ability and training. The report anticipated that planned rotations of all staff grades between sites within the emergency surgery network, would improve and standardise care as well as enhance recruitment and retention.

The report’s key recommendations include:

  • New emergency surgery networks should include injury units, emergency surgery units and emergency surgical centres, with each network supported by access to an Elective Hospital.
  • Emergency surgery centres should have availability of interventional radiology services and endoscopy on a 24/7 basis.
  • Each hospital accepting emergency surgery patients should have an Acute Surgical Assessment Unit.
  • Emergency and elective surgery should be carried out by the same consultant surgeon workforce in volumes sufficient to maintain the competence of the entire surgical team.
  • Emergency duties and scheduled activity should be separate to allow consultant provided care, service continuity and to enable high quality surgical training.
  • Consultant surgeons should work across more than one site in the network to enable full participation in both emergency and scheduled care activities.
  • With appropriate policies and safeguards, senior surgical decision-maker rosters at emergency surgery units could include not only consultant surgeons but also senior surgical trainees, non-training grade doctors, advanced nurse practitioners and other health and social care professionals.
  • Opportunities to increase Advanced Nurse Practitioner and Physician Associate participation in the emergency surgery workforce should be explored.

The report calls for a national agreement on the optimal staffing model for consultant surgeons who deliver emergency general surgery.

It said hospitals with an emergency surgery unit required staffing to perform appropriate emergency surgery for 8-12 hours, either 5 or 7 days per week, depending on their geographic location and caseload.

Consultant surgeons should work across more than one hospital in the network to enable full participation by each surgeon in both emergency and scheduled care services. Emergency and elective surgery should be carried out by the same consultant surgeon, ideally in high volume centres. The activity should be separate and should enable high quality surgical training to take place to ensure a sustainable service for the future.

Timely access of patients to UGI, HPB and colorectal specialist surgeons was critical to enable best outcomes in cancer and other complex conditions presenting as an emergency to be achieved.

A clear governance structure for acute surgical care, taking into account regional health area networks for delivery of acute surgery, both general and sub-specialist, was required. An interdisciplinary workforce plan for emergency general surgery should include nursing, anaesthesiology, physician associates and access to diagnostics and critical care resources. Opportunities to increase advanced nurse practitioner (ANP) and physician associate (PA) participation in the emergency surgery workforce should be prioritised. Policy relating to provision of emergency surgery for children should be agreed by relevant stakeholders.

The report said a Model of Care for Acute Surgery, published in 2013, described a system of care in which elective and emergency surgery were delivered as distinct entities, but has been incompletely implemented. As a result, in many hospitals, surgeons providing emergency surgery typically had a number of other commitments. Such commitments varied by whether the surgeon was employed in a Model 3 or Model 4 hospital and whether the hospital was an NCCP-designated cancer centre.

In most hospitals, emergency surgery was just one of a range of services delivered synchronously with a range of elective adult and paediatric surgery, cancer surgery, significant volumes of endoscopy and ambulatory procedures and out-patient clinics. In the eight cancer centres, for example, services were delivered by consultant general surgeons from a range of sub-specialties (namely breast and endocrine, upper gastrointestinal, colorectal, hepatobiliary pancreatic surgery) each of whom was also responsible for the delivery of highly specialised cancer and complex benign surgery within their area of expertise.

There was significant variation between hospitals in roster intensity, admission volume and operative complexity, and in the number of patients admitted as an emergency but not undergoing emergency surgery between hospitals. 

Launching the report, RCSI Vice-President Prof. Deborah McNamara said, “Access to high quality emergency surgical care is lifesaving and must be available to everyone. Greater life expectancy among Irish people means that emergency surgery patients are more complex and have greater co-morbidity so the demands on our health service to deliver this care will continue to increase. At the same time, advances in surgery, interventional radiology and endoscopy mean that more treatment options than ever before are now available to surgeons and their patients. The majority of emergency operations can be delivered safely in most hospitals, but the current system, with onerous on-call rotas and low volumes of high risk cases in many hospitals, makes it difficult for the more complex emergency patients to receive the care they need.

“Emergency surgery is safest when performed during normal working hours by fully- trained staff and where sufficient volumes of surgery are performed to maintain the expertise of the multidisciplinary emergency surgery team. A networked system of emergency surgical care enables most emergency surgical care to be delivered as near as possible to the patient’s home while ensuring equitable access to complex care when required.”

The report was launched at Charter Day, which marks the annual celebration of the granting of Royal Charter to the College in 1784.