Emergency General Surgery
at Aintree
The Emergency General Surgical Unit
Experiment
Mr Richard Ward, Consultant Surgeon

Traditional system
• Patients admitted
under duty consultant
– Any available bed
• Mix of specialities
• Emergency and
elective patients
mixed
• Multiple outlying
patients away from
consultant base ward
• Huge variation in
juniors workload
• Inconsistent team

0
5
10
15
20
25
30
35
40
45
Weds
12
Thurs
13
Fri 14 Sat 15 Sun 16 M on 17 Tues
18
Weds
19
Thurs
20
Fri 21 Sat 22 Sun 23 M on
24
Tues
25
Weds
26
Thurs
27
Fri 28 Sat 29 Sun 30 M on 1 Tues 2 Weds
3
Non-elective general surgical inpatients
Elective pathw ay inpatients
& subspeciality emergencies
F1 Annual leave
F2 Annual leave F2 nights
SpR nights
Consultant study
leave
Consultant on
call periods
3 session list
Grand round, list cancellation

Emergency General Surgical Unit
35 beds plus two cubicles as follows:-
Ward 1
4 x 5 bed bays
3 single rooms
Surgical
Assessment
Unit
2 x 5 bed bays
2 single rooms
Assessment
Area
2 cubicles

New System
• Patients admitted
under EGSU
consultant
• EGSU only
• Subsequent pathway
– Admit under relevant
subspeciality team
– Discharge and review
by EGSU consultant
• Advantages
– Patients receive care
from appropriate
subspeciality surgeon
– Reduced surgical
outliers
– Reduced post take
wardrounds
– Even juniors workload

Patient Access
• A&E to SAU
– Via duty F2/CT1-2
• SpR / consultant review
• GP
– Via unplanned care direct
• A&E triage
• F1 assessment
• F2/CT1-2 or Spr assessment
– Admit to EGSU bed
– Discharge

Emergency General Surgical Unit,
weekday staffing
• Medical Staff
– Consultant 0800 – 1730
– Registrar (LAS)
– F1 0800 – 1600
– Duty Team
• SpR
• F2 / CT1/2
• F1
• Nursing Team

Emergency General Surgical Unit,
evening, night and weekend
staffing
• Medical Staff
– Consultant on call
Duty Team
• SpR
• F2 / CT1/2
• F1
• Nursing Team

EGSU handover 0800
• Consultant EGSU and Consultant on call
• SpR
– Daytime coming on
– Night shift leaving
– SpR from Consultant on call team
• F2/CT
– Daytime
– Night shift
• F1
– EGSU
– Daytime
– Night shift
– Ward 3 F1 from subspeciality of on call consultant

EGSU January 2010
• EGSU board set up
– Lead clinician
– Divisional Medical Director
– Surgeons
– Anaesthetists
– A&E rep
– Radiol rep
– Ward manager EGSU
– Management
• Simon Barton
• Dave Warwick
– Matron
• Lead clinician
(Consultant) starts in post
– Ex vascular surgeon
– 18 years pre consultant
general surgery emergency
experience
– Urology
– Upper gi
– Colorectal
– Transplant

Why do patients need to be in
hospital?
• Clinical opinion
• Symptom control
• Treatment
• Investigation
• Respite
• Is this a life
threatening illness?
• Are symptoms
controlled?
• Is hospital treatment
necessary?
• Investigate as an out
patient!

patients per consultant - EGSU effect
0
5
10
15
20
1 2 3 4 5 6 7 8 9
days [on call day 2]
numberofpatients
post egsu
pre egsu

Average length of stay WARD1
-
1.0
2.0
3.0
4.0
5.0
6.0
06-Sep-09
13-Sep-09
20-Sep-09
27-Sep-09
04-Oct-09
11-Oct-09
18-Oct-09
25-Oct-09
01-Nov-09
08-Nov-09
15-Nov-09
22-Nov-09
29-Nov-09
06-Dec-09
13-Dec-09
20-Dec-09
27-Dec-09
03-Jan-10
10-Jan-10
17-Jan-10
24-Jan-10
31-Jan-10
07-Feb-10
14-Feb-10
21-Feb-10
28-Feb-10
07-Mar-10
14-Mar-10
21-Mar-10
28-Mar-10
04-Apr-10
11-Apr-10
18-Apr-10
25-Apr-10
02-May-10
09-May-10
16-May-10
23-May-10
30-May-10
AverageLengthofStay(Days)
Unit Number (All) DATEONWARD (All) AdmissType Non Elective Month (All) MAINSPEC 1000 CONSULTANT (All) WARD (EVENT) (All)
Average of WardLoS
WeekEnding

Non-elective surgical discharges
DDU Non Elective Discharges
0
50
100
150
200
250
300
350
400
450
Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10
Discharges
0%
10%
20%
30%
40%
50%
60%
70%
80%
%DischargedfromSAU/WARD01
SAU / WARD 01 OTHER WARDS % DISCHARGED FROM SAU / WARD 01

EGSU paradox
• 5% reduction in
admissions
• Reduced average
length of stay
• 50 bed days per week
saved
• £340,000 surplus of
income over
expenditure [1st
quarter 2010 – 2011]
• £1,000,000 lost
income to Trust

The Challenges
• The future – is this the system best suited
to the needs of the Trust?
– Continuity planning
• Service redesign
• Training – how to harness the potential?
• Teaching
• Audit
• Research

The End
(of the Beginning)
Thank You

General surgery FCE’s

General Surgery: Census WTEs
2006

• 1539 audited deaths after
surgery (525,867 total ops)
• 92% urgent/emergency
• 17% areas for concern
Main areas of concern
• “Unsatisfactory medical
management,
• Fluid management 13%
• 40% never in ICU/HDU
• Poor process of care

Comparison of P-Possum risk adjusted
mortality rates after non-cardiac surgery between patients in
USA and UK.
Bennett-Guerrero E, Hyam JA, Prytherch DR, Sutton GL, Weaver PC,Mythen MG, Grocott
MP, Parides MK.
Br J Surg 2003:90:1593-1596
• Similar major surgery
in UK v US
• Risk adjusted
• Four times
more likely to die in
UK!

NCEPOD 2007 on Trainees
Delays in seeing a doctor of adequate seniority and experience may have a
detrimental effect on patient care
Decision making by training grades
 examples of lack of decision making by trainees
 Quality of decisions by trainees poor
Ability of trainees to recognise critical ill patients is poor
 examples of trainees underestimating the severity of physiological
dysfunction
The restriction on junior doctors hours poses challenges for
training, assessment of competence and for continuity of care

What is Required
(ASGBI 2007)
Separate Elective and
Emergency Surgery
Centralisation of Emergency
Services
Emergency General Surgeons
Raise the Standards of
Emergency Surgery

Emergency General Surgical Unit
• Patients
Emergency
General Surgery
Urology M F U
Other
Vascular
Orthopaedic
E N T

Emergency Workload
• Common – 80%
– Biliary 13%
– Urology 11%
– Dyspepsia 11%
– Pelvic pain 8%
– Colonic lesions 8%
– Appendicitis 6%
– Abscesses 5%
– S B obstn 5%
– Perianal abs 4%
• Uncommon
– Head injury 2%
– Perforation 2%
– Blunt trauma
– Perforating trauma

Obstruction 2010

Postoperative problems

Postoperative problems 2

Oops!

. Average Length of Stay: Ward 11 / Ward 3 Combined
-
1.0
2.0
3.0
4.0
5.0
6.0
7.0
06-Sep-09
13-Sep-09
20-Sep-09
27-Sep-09
04-Oct-09
11-Oct-09
18-Oct-09
25-Oct-09
01-Nov-09
08-Nov-09
15-Nov-09
22-Nov-09
29-Nov-09
06-Dec-09
13-Dec-09
20-Dec-09
27-Dec-09
03-Jan-10
10-Jan-10
17-Jan-10
24-Jan-10
31-Jan-10
07-Feb-10
14-Feb-10
21-Feb-10
28-Feb-10
07-Mar-10
14-Mar-10
21-Mar-10
28-Mar-10
04-Apr-10
11-Apr-10
18-Apr-10
25-Apr-10
02-May-10
09-May-10
16-May-10
23-May-10
30-May-10
AverageLengthofStay(Days)
Unit Number (All) DATEONWARD (All) AdmissType (All) Month (All) MAINSPEC (All) CONSULTANT (All) WARD (EVENT) (All)
Average of WardLoS
WeekEnding

0
5
10
15
20
25
30
35
40
45
Weds
12
Thurs
13
Fri 14 Sat 15 Sun 16 M on 17 Tues
18
Weds
19
Thurs
20
Fri 21 Sat 22 Sun 23 M on
24
Tues
25
Weds
26
Thurs
27
Fri 28 Sat 29 Sun 30 M on 1 Tues 2 Weds
3
Non-elective general surgical inpatients
Elective pathw ay inpatients
& subspeciality emergencies
F1 Annual leave
F2 Annual leave F2 nights
SpR nights
Consultant study
leave
Consultant on
call periods
3 session list
Grand round, list cancellation

SURGICAL DIVISION bed occupancy 09/10
total
elective
nonelective

SURGICAL DIVISION September 2010
0
500
1000
1500
2000
2500
3000
elective nonelective
beddays
right bed
other

EGSU – the weakness
• Single handed
consultant
• 0800 – 1800
weekdays
• Laparoscopic
incompetent
• Past it?

Average length of stay, EGSU
0
1
2
3
4
5
6
7
19/07/2010
25/07/2010
01/08/2010
08/08/2010
15/08/2010
22/08/2010
29/08/2010
05/09/2010
12/09/2010
19/09/2010
26/09/2010
average
days
Series1
Series2

Non Elective Surgical admissions
Non Elective Surgical Admissions
500
550
600
650
700
750
800
850
900
950
2008-09
2009-10
2008-09 884 871 793 773 803 801 865 847 839
2009-10 812 830 783 808 869 776 865 777 859
Sep Oct Nov Dec Jan Feb Mar Apr May

Average los - SAU
1. Average Length of Stay: Surgical Assessment Unit
-
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
06-Sep-09
13-Sep-09
20-Sep-09
27-Sep-09
04-Oct-09
11-Oct-09
18-Oct-09
25-Oct-09
01-Nov-09
08-Nov-09
15-Nov-09
22-Nov-09
29-Nov-09
06-Dec-09
13-Dec-09
20-Dec-09
27-Dec-09
03-Jan-10
10-Jan-10
17-Jan-10
24-Jan-10
31-Jan-10
07-Feb-10
14-Feb-10
21-Feb-10
28-Feb-10
07-Mar-10
14-Mar-10
21-Mar-10
28-Mar-10
04-Apr-10
11-Apr-10
18-Apr-10
25-Apr-10
02-May-10
09-May-10
16-May-10
23-May-10
30-May-10
AverageLengthofStay(Days)
Unit Number (All) DATEONWARD (All) AdmissType (All) Month (All) MAINSPEC (All) CONSULTANT (All) WARD (EVENT) SURGICAL ASSESSMENT UNIT
Average of WardLoS
WeekEnding

Emergency Admissions:
A journey in the right direction?
A report of the National Confidential Enquiry
into Patient Outcome and Death (2007)

WTR - Hours of Experience & Training
Pre-2004 Aug 2004 Aug 2009 + MMC
Basic
Surgical
Training
7000 6000 2600 /
Higher
Surgical
Training
14000 11500 5040 /
Total 21,000 17,500 7,640 6,000

• Essential prerequisite for the CCT in General Surgery is
competence to manage unselected general surgical
emergencies
• Largest component of EGC case-mix is gastrointestinal –
equates to proposed ‘specialist gastrointestinal surgeon’
• Both upper and lower GI surgeons competent in field of
EGS with occasional backup from other specialist colleagues
Emergency General Surgery Consensus Cont.

ASGBI supports:
• Development of outcome related standards of care in
Emergency General Surgery.
• Care of emergency surgical patients delivered equal to
standards accepted for elective surgical practice
• Fundamental principle of maintaining high quality outcomes for
all surgical patients whether elective or emergency
Emergency General Surgery Consensus Cont.

High risk surgical patients
that die often not admitted
to critical care
Critical Care
Beds
Total Level 3 ICU Level 2 HDU
Total 2566
(0.5/10,000
)
1486
(0.3/10,000)
1080
(0.2/10,000)
 “Critical care gap”
 Preventing Surgical deaths: critical care and intensive care outreach in the postoperative
period. Goldhill DR. BJA 2005;95:88-94.
 DOH Census data for England July 2007 (Beds Open and Staffed)
 US 3 per 10,000 population (may need more with less experience)

Conflicting Pressures
• Changing pattern of disease
• Greater patient expectation
• Impact of screening
• Increasing elderly population
• New options for treatment
• Increasing move to minimal invasive
treatment
• Increasing evidence for value of non-
surgical treatments

ASGBI EMERGENCY GENERAL SURGERY:
THE FUTURE. A CONSENSUS STATEMENT
JUNE 2007
• Wide variation in the quality of Emergency General Surgery (EGS)
• A huge clinical service - one of most common reasons for admission to
a surgical bed
• ASGBI recognises critical need for dedicated clinical leadership of EGS
-not simply the ‘on-call’ consultant.
• Care of emergency admissions often takes second place to care of
elective patients
• Clear and identifiable separation of delivery of emergency and elective care