J.R. Coll. Surg. Edinb., 42, December 1997, 381—382
General surgery section
Can emergency general surgical referrals be reduced? A prospective study
D.J. BOWREY, J. M. D. WHEELER, R. 0. N. EVANS,
L. J. FLIGELSTONE AND K. D. VELLACOTT
Department of Surgery, Royal Gwent Hospital, Cardiff Road,
Newport, Gwent NP9 2UB, UK
It has been proposed that early assessment by a senior surgeon would result in a significant reduction in the number of general surgical admissions.’ A prospective study of 290 surgical patients admitted to a busy district general hospital over a period of 1 calendar month has been performed to test this hypothesis. After admission, all patients were assessed by a senior surgeon who carried out triage for each patient. The commonest diagnoses in descending order of frequency were non-specific abdominal pain, appendicitis, diverticular disease, cholecystitis, head injury and pancreatitis. Twenty-two per cent of emergency admissions underwent emergency surgery. A total of 90.7% of admissions were deemed appropriate, 5.5% were deemed inappropriate and in 3.8% of cases the senior surgeon was uncertain as to whether the patient should be admitted or not. Our data fail to substantiate the claim that a significant reduction in intake size would be achieved by early assessment by a senior surgeon. Assessment by surgeons may mean sacrificing other clinical commitments, and is likely to result in a diminution in the standard of both basic and higher surgical training.
Keywords: emergency, reduction in numbers, surgical admissions.
A recent study has suggested that initial assessment of emergency general surgical patients by a senior surgeon would substantially reduce the number of admissions1. Given the current awareness of the financial implications of differing clinical practice within the National Health Service, any potential measures that would reduce the number of admissions and thus subsequent expenditure should be exploited. The study aim was to evaluate the above suggestion.
A prospective analysis of all patients admitted to the acute surgical intake was performed for 1 calendar month (March 1995). Referral for emergency surgical admission is to the on-call pre-registration house officer by the general practitioner, and to the on-call senior house surgeon by the accident and emergency department. At the Royal Gwent Hospital it is policy that acute surgical patients can only be discharged by a surgeon of specialist registrar grade or above.
The following data were recorded for each patient: date and time of admission; presenting symptoms and signs; baseline observations; haematology and biochemistry results; radiographic findings; and diagnosis on arrival.
Following admission to the surgical ward, all patients were assessed by either a consultant surgeon or a higher surgical trainee who allocated each patient to the following categories: (i) appropriate referral; (ii) inappropriate referral; and (iii) uncertain. Patients were followed up until their discharge from hospital, and the final diagnosis and date of discharge from hospital were recorded. Where appropriate, the results of out-patient investigations were awaited.
During the study period the on-call rota was 1:5, with middle-grade cover for the five consultants provided by two senior registrars (years 5 and 6 specialist registrar equivalents), a staff-grade surgeon (year 4 specialist registrar equivalent), and two post-fellowship senior house surgeons. For the study purposes the term ‘senior surgeon’ denoted the five consultants, the senior registrars and the staff-grade surgeon.
Three hundred and five patients were admitted to the general surgical intake during the study period. Complete data were available on 290 patients, representing 95% of admissions. The mean age of the 162 male and 128 female patients was 44 years (range 6 months to 100 years). The principal diagnoses at discharge were non-specific abdominal pain (44 patients, 15%), appendicitis (29 patients, 10%), diverticular disease (24 patients, 8%), cholecystitis (24 patients, 8%), head injury (21 patients, 7%) and pancreatitis (15 patients, 5%).
Sixty-three patients (22%) underwent emergency surgery. The commonest operations performed were appendicectomy (26 patients, 41%), abscess drainage (13 patients, 21%), laparotomy (10 patients, 16%), scrotal exploration (six patients, 10%), and exploration/repair of hernia (six patients, 10%). A further 13 patients (4%) underwent surgery at the same admission but on elective rather than emergency theatre lists; laparotomy accounted for three-quarters of these procedures.
Of the 290 admissions, 263 (90.7%) were deemed appropriate (assessor: consultant 139; higher surgical trainee 124) and 16
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(5.5%) were deemed inappropriate (assessor: consultant seven; higher surgical trainee nine). In 11 cases (3.8%) the senior surgeon (consultant five; higher surgical trainee six) was undecided as to whether admission was warranted. There were no significant differences between consultants and higher surgical trainees in the proportion of patients placed in each of the three groups (X2 = 0.70, P= 0.70).
The diagnoses of those that were deemed inappropriate admissions were urinary tract infection (four), non-specific abdominal pain (three), long-standing asymptomatic hernias (two), constipation (two), scrotal bruising following an injury five days previously (one), goitre (one), vomiting secondary to alcohol intoxication (one), palpable abdominal mass (one), and long-standing gynaccologic symptoms (one).
The diagnosis producing uncertainty regarding appropriateness for emergency admission were non-specific abdominal pain (two), urinary tract infection (two), gastroenreritis (two), rectal bleeding due solely to haemorrhoids (one), uncomplicated hydrocoele (one), constipation (one), weight loss (one) and goitre causing dysphagia (one).
The mean in-patient stay was 5.0 days. There were 11 in-patient deaths (3.8%), due to carcinomatosis (four), myocardial infarction (two), pulmonary embolism (one), septicaemia due to appendicitis (one), perforated duodenal ulcer (one), faecal peritonitis from perforated sigmoid diverticular disease (one) and pancreatitis (one). The mean age of these patients was 77.2 years (range 66—91 years). The 30-day operative mortality rate was 0.3% (one ease of acute perforated appendicitis in a nonagenarian).
The main finding of our study does not support the claim that the number of patients hospitalized would be significantly reduced by initial assessment by a senior surgeon. At our institution this would have reduced acute admissions by 5.5%. The previous study’ utilized specialized radiological facilities (immediate access ultrasonography and radiograph reporting by a radiologist), facilities that are often unavailable.
Potential fiscal benefit in terms of a reduced intake size is fraught with logistic problems. The provision of immediate assessment by the nominated senior surgeon would require two notional sessions per week solely for this purpose. It is difficult to fit this into the modern consultant contract, and would require either the rescheduling or the complete relinquishment of out-patient clinics and theatre sessions on the proposed intake day. The potential savings from a reduction in ‘hotel costs’ of those patients able to be discharged are likely to be offset by an unacceptable increase in outpatient and in-patient waiting times, with the attendant financial penalties that these carry. A reduced commitment to clinical sessions is also likely to result in a dilution of training; this is hazardous, more so now given the reduction in the duration of training as proposed by the Calman scheme.2
Referrals for admission by general practitioners at this institution involve the general practitioners liaising directly with a member of the on-call surgical team. If appropriate, the referring general practitioner can liaise with the on-call higher surgical trainee to arrange an urgent clinic referral. Referrals for admission by general practitioners in the previous study were dealt with via a bed bureau system, whereby clerical staff act as intermediaries conveying patient information to the admitting junior hospital staff. This system is popular with the general practitioners, as it avoids any potential delay in awaiting a response to a pager. It appears to be less popular with junior hospital staff as the quality of information tends to be reduced and direct dialogue with the general practitioner is generally discouraged.
Admission to hospital may be required for many reasons, in a manner similar to the principle of Gestalt, where the whole is greater than the sum of the parts. Assessment of a patient in poor light at home, under the gaze of anxious hovering relatives, would humble even the greatest diagnostician. Often it takes careful repeated observation to obtain a definitive diagnosis, even with the latest diagnostic aids. The practice of medicine remains in part a science and in part an art. Although proper allocation of funding and a desire to reduce expenditure are admirable, we believe that it is unlikely that immediate discharge from hospital would produce a reduction in costs.
1 Gaskell DJ, Crosby DL, Feon N, Lewis PA, Roberts CJ, Roberts SM. Improving the primary management of emergency surgical admissions: a controlled trial. Ann R Coll Surg Engl (Suppl) 1995; 77:239-41.
2 Hospital Doctors: Training for the Future. The report of the working group no specialist medical training (the Calman Report). Department of Health 1993, MISC (93) 31.
Correspondence: Mr David Bowrey, Surgical Research Fellow, University Department of Surgery, Heath Park, Cardiff CF4 4XN, UK
© 1997 The Royal College of Surgeons of Edinburgh, J R. Coll. Surg. Edinb., 42, December, 381—381