Determinants of access to emergency surgery according to resident doctors: A cross-sectional study at a teaching hospital in Ibadan, Nigeria

Background Morbidity and mortality following emergency surgeries can be reduced with timely access to emergency surgery and five billion people globally, lack access to essential surgery. Data on the determinants of these are still lacking. Objectives We studied resident doctors' perspectives of the patient-, healthcare-giver-, and health-institution-related determinants of access to emergency surgery at the University College Hospital, Ibadan, Nigeria. Methodology This self-administered, questionnaire-based, cross-sectional survey involved eighty-five resident doctors; recruited using systematic random sampling. Ethical approval (UI/EC/20/0318) and prospective registration (NCT04487496) were obtained. Results Major patient-related sources of delays included financial constraints (97.7%), patient's consent (78.8%), guardian's consent (74.1%) and diagnosis denial (70.6%). Anaesthetists (65.9%) caused and surgeons (61.2%) reduced delays. The healthcare-giver factors were provision of blood (84.7%), optimization of patient (83.5%), unavailable theatre space (82.4%), anaesthetic personnel fatigue (67.1%), surgical personnel fatigue (43.5%) and time-to-diagnosis (58.8%). Diagnostic delays were mostly from investigations (97.6%) and missed diagnosis (47.1%). Unavailable bedspace (82.4%), delays in arrival (82.4%) and entry (74.1%) into the theatre were major health institution challenges. Establishing diagnosis was delayed by payment for (96.5%) and doing (88.2%) diagnostic investigations, and time-to-review by specialist team (80.0%). Arrival in theatre was affected by theatre trolley conveying patient (70.6%), pre-anaesthesia review (70.6%) and pre-operative nursing logistics (64.7%). Entry into the suite depended on payment/payment deferment (87.06%) and suites being unavailable (75.3%). Conclusion patient, and the surgical procedure. The patient factors were poor finances, diagnosis denial and giving of consent for surgery. We encourage (recommend) physician-run point-of-care diagnostics in emergency rooms (ER), with improved health insurance coverage, ER bedspace, and personnel (surgical and anaesthesiological).

Acute Care Surgery: Implementation in Korea

The concept of acute care surgery (ACS) incorporates trauma, surgical critical care, and emergency general surgery. It was designed in the early 2000s by the United States as a solution to the looming crisis of trauma care and non-trauma emergency surgery. Reduced surgical opportunities for trauma surgeons resulted in a decreased interest in trauma surgery. Surgical sub-specialization further accelerated an indifference towards trauma and emergency general surgery. Started in 2008, the trauma center project in Korea is still in its infancy. Although the need for ACS was presented since the inception of the trauma center project, there was a lack of implementation at trauma centers due to government regulations. However, ACS has been initiated at several non-trauma center hospitals and is mainly operated by surgical intensivists. Studies demonstrate that adding emergency surgery to a trauma service does not compromise the care of the injured patients, despite an increase in trauma volume. Positive impacts of ACS are reported by numerous researches. We believe that the development and advancement of trauma centers will necessitate a discussion for the implementation of the ACS model at trauma centers in Korea.

Acute Care/Trauma Surgeon's role in obstetrical/ gynecologic emergencies (The OBCAT Alert) / 世界急诊医学杂志（英文）

@#BACKGROUND: Overwhelming hemorrhage or other intra-abdominal complications may be associated with obstetrical or gynecologic (OB/GYN) procedures and may require the surgical training of an Acute Care/Trauma Surgeon. The OB Critical Assessment Team (OBCAT Alert) was developed at our institution to facilitate a multidisciplinary response to complex OB/GYN cases. We sought to review and characterize the Acute Care/Trauma Surgeon's role in these cases. METHODS: We conducted a retrospective review of all emergency consults during an OB/GYN case at our institution from 2008 to 2015. An OBCAT is a hospital based alert system designed to immediately notify OB/GYN, anesthesiology, Acute Care/Trauma, the intensive care unit (ICU), and the blood bank of a potential emergency during an OB/GYN case. RESULTS: There were 7±3 OBCAT alerts/year. Seventeen patients required Acute Care/Trauma surgery intervention for hemorrhage. Thirteen patients required damage control packing during their hospitalization. Blood loss averaged 6.8±5.5 L and patients received a total of 21±14 units during deliveries with hemorrhage. There were 17 other surgical interventions not related to hemorrhage; seven of these cases were related to adhesions or intestinal injury. Seven additional cases required evaluation post routine OB/GYN procedure; the most common reason was for severe wound complications. There were three deaths during this study period. CONCLUSION: Emergency OB/GYN cases are associated with high morbidity and may require damage control or other surgical techniques in cases of overwhelming hemorrhage. Acute Care/Trauma Surgeons have a key role in the treatment of these complex cases.

Changing models of care for emergency surgical and trauma patients in Singapore

The last 15 years have seen changing patterns of injury in emergency surgery and trauma patients. The ability to diagnose, treat and manage these patients nonoperatively has led to a decline in interest in trauma surgery as a career. In addition, healthcare systems face multiple challenges, including limited resources, an ageing population and increasing subspecialisation of medical care, while maintaining government-directed standards and managing public expectations. In the West, these challenges have led to the emergence of a new subspecialty, 'acute care surgery', with some models of care providing dedicated acute surgical units or separating acute and elective streams with the existing manpower resources. The outcomes for emergency surgery patients and efficiency gains are promising. In Singapore, Khoo Teck Puat Hospital has implemented its first dedicated acute surgical unit. This article outlines the evolution of acute care surgery and its relevance to Asia.