The use of Acute Care Emergency Surgical Service (ACCESS) in emergency departments (EDs) can lead to significant reductions in key patient measures, such as length of stay, surgical decision-making time and "time-to-stretcher" (one measure of overall ED overcrowding), according to a study published in the August issue of the Journal of the American College of Surgeons. Emergency departments are a crucial point of access to the health care system for patients with a broad spectrum of injuries and illnesses, and overcrowding has been identified as a widespread and serious problem with adverse consequences, both in the United States and Canada.
"This study is the first to show that the establishment of an acute care surgery service can improve overall ED overcrowding by decreasing surgical decision time for all general surgery patients," said Homer Tien, MD, MSc, FACS, FRCSC and associate scientist at the Sunnybrook Health Sciences Centre, University of Toronto, and a senior author of the study. "In the past five years, there has been a groundswell of support in both Canada and in the U.S. for establishment of these services for various reasons, such as the growing difficulty of treating acute surgical conditions and a decrease in operative trauma surgical cases."
The researchers found that implementation of ACCESS was associated with a 15 percent reduction in surgical decision time (12.6 hours vs. 10.8 hours, p < 0.01) and a 20 percent decrease in the average "time-to-stretcher" for all ED patients. The researchers also focused on an isolated group of appendicitis cases and found ACCESS service reduced surgical decision time by 30 percent for these patients. The study was performed between January 1, 2007, and June 30, 2009, at Sunnybrook Health Sciences Centre, a large academic hospital located in Toronto that receives approximately 42,000 ED visits annually. ACCESS was implemented in the ED on July 1, 2008 and 2,510 patients took part in the study. There were 1,448 patients studied pre-ACCESS and 1,062 studied post-ACCESS implementation. The primary study outcome was surgical decision time; the secondary outcome was a measure of overall ED overcrowding.
In order to better understand the key factors contributing to overcrowding, study authors developed a conceptual model that partitioned ED overcrowding into three interdependent components: input, throughput and output. The input component refers to factors that contribute to the volume of care delivered in the ED. The throughput component refers to factors that contribute to the amount of time a patient spends in the ED. The two main options for output are admission to a hospital bed or discharge. The inability to move patients from the ED to an inpatient bed is considered one of the major contributing factors to ED overcrowding.
Acute care surgery is defined as the urgent assessment and treatment of non-trauma general surgical emergencies (i.e., appendicitis, diverticulitis, bowel obstruction, bilary disease, postoperative complications).