An acute care surgery model improves outcomes in patients with appendicitis.

OBJECTIVE: To compare outcomes of appendectomy in an Acute Care Surgery (ACS) model to that of a traditional home-call attending surgeon model. SUMMARY BACKGROUND DATA: Acute care surgery (ACS, a combination of trauma surgery, emergency surgery, and surgical critical care) has been proposed as a practice model for the future of general surgery. To date, there are few data regarding outcomes of surgical emergencies in the ACS model. METHODS: Between September 1999 and August 2002, surgical emergencies were staffed at the faculty level by either an in-house trauma/emergency surgeon (ACS model) or a non-trauma general surgeon taking home call (traditional [TRAD] model). Coverage alternated monthly. Other aspects of hospital care, including resident complement, remained unchanged. We retrospectively reviewed key time intervals (emergency department [ED] presentation to surgical consultation; surgical consultation to operation [OR]; and ED presentation to OR) and outcomes (rupture rate, negative appendectomy rate, complication rate, and hospital length of stay [LOS]) for patients treated in the ACS and TRAD models. Questions of interest were examined using chi tests for discrete variables and independent sample t test for comparison of means. RESULTS: During the study period, 294 appendectomies were performed. In-house ACS surgeons performed 167 procedures, and the home-call TRAD surgeons performed 127 procedures. No difference was found in the time from ED presentation to surgical consultation; however, the time interval from consultation to OR was significantly decreased in the ACS model (TRAD 7.6 hours vs. ACS 3.5 hours, P < 0.05). As a result, the total time from ED presentation to OR was significantly shorter in the ACS model (TRAD 14.0 hours vs. ACS 10.1 hour, P < 0.05). Rupture rates were decreased in the ACS model (TRAD 23.3% vs. ACS 12.3%, P < 0.05); negative appendectomy rates were similar. The complication rate in the ACS model was decreased (TRAD 17.4% vs. ACS 7.7%, P < 0.05), as was the hospital LOS (TRAD 3.5 days vs. ACS 2.3 days, P < 0.001). CONCLUSIONS: In patients with acute appendicitis, the presence of an in-house acute care surgeon significantly decreased the time to operation, rupture rate, complication rate, and hospital length of stay. The ACS model appears to improve outcomes of acute appendicitis compared with a TRAD home-call model. This study supports the efficacy and efficiency of the ACS model in the management of surgical emergencies.

The evolving role of interventional radiology in trauma care.

BACKGROUND: Although the traditional role of radiology in trauma care has been diagnostic, therapeutic interventional radiology (IR) techniques have now become essential in the management of many injuries. We hypothesized that IR has evolved at our institution over the last decade from a largely diagnostic to a more therapeutic role in the care of the injured patient. METHODS: Demographic information, computed tomographic scans of the chest and abdomen, and angiographic procedures (APs) performed within 48 hours of admission were reviewed in all patients evaluated at a Level I trauma center for the periods 1993 to 1995 and 2000 to 2002. All APs performed with the intent to embolize, stent, or insert a device into a vessel were designated as therapeutic. Analysis by means of chi provided between-group comparisons for questions of interest and the Student's t test was used for comparison of means. RESULTS: A total of 4,750 patients were reviewed, 1,677 from the time period 1993 to 1995 and 3,073 from the period 2000 to 2002. Overall injury severity as measured by the Injury Severity Score (ISS) was similar in both groups (9.6 vs. 9.9, p = not significant). The number of angiograms obtained decreased significantly from 7.1% to 4.0% of all patients (p < 0.01). Concurrently, the fraction of all angiograms that were considered therapeutic rose from 10% to 22% (p < 0.05). The overall number of aortic arch angiograms decreased over time (from 3.6% to 0.9%, p < 0.01), and the percentage of positive examinations increased from 5.0% to 21.4%. In comparison, the number of computed tomographic scans of the chest increased from 1.6% of all patients to 10.8% (p < 0.01). CONCLUSION: Axial imaging studies are being used more frequently to screen trauma patients for injury. Concurrently, diagnostic APs are less frequently performed but are more frequently positive. In addition, IR studies are increasingly focused on therapeutic intervention. IR program development and support is an integral aspect of modern trauma care. These findings have prompted our institution to equip the IR suite to function as an active resuscitation area similar to the trauma bay and intensive care unit.