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Proposal for a new specialty: emergency general surgery

Authors: Nebil Behar, Dominic King 

Publication date:  07 Jul 2012


Nebil Behar and Dominic King consider whether it’s time for a new specialty

Emergency patients account for about half of the surgical workload in the NHS, but standards of management of unscheduled surgical patients vary widely and are often suboptimal.[1] The pressure of managing elective and emergency workloads together is a challenge for healthcare providers faced by tightening financial budgets, waiting list targets, and the requirements of the European Working Time Directive. If well planned, however, separation of elective and emergency care can lead to more predictable workflows, shorter hospital stays, enhanced training opportunities, and financial savings for hospital trusts.[2] Given the predicted benefits of separation, the Royal College of Surgeons of England has recommended that, where possible, elective surgical services should be separated from emergency admissions.[3]

How hospitals provide safe and effective emergency surgical care often depends on local circumstances and available resources. Consultant cover for unscheduled emergency admissions has traditionally come from staff with coexisting elective interests, but different models are now being implemented (box 1). In general surgery, where much of the work is emergency care, we believe that patients and funders could benefit from a new specialty of emergency general surgery, where unscheduled emergency admissions are managed by a dedicated consultant led team. While there are only a handful of substantive consultant posts in emergency general surgery in the NHS, with demand this number is expected to grow in the next decade. We describe our experience in a novel emergency general surgery service at Chelsea and Westminster Hospital and give some of our thoughts on setting up a similar service and the best way a new subspecialty can grow in the future.

Box 1: Options for providing consultant led emergency surgical services

  • Status quo—Consultants continue to provide elective services while covering unscheduled admissions when on call

  • Consultants of the week—Cancel most of their elective work during their on-call period and concentrate on providing an emergency service

  • Consultants with a special interest in emergency surgery—Dedicate part of their regular week to care of unscheduled admissions but also have substantial elective commitments

  • Consultants in emergency surgery—Prioritise the management of unscheduled admissions, with little or no fixed commitment to elective care (such as clinics and scheduled operating lists)

Chelsea and Westminster experience

The department of general surgery at Chelsea and Westminster Hospital provides general and specialist colorectal, bariatric, and endocrine services. There are no inpatient vascular or breast services, and major trauma patients are diverted to local trauma centres. Elective and emergency surgical activities were separated at the hospital in 2008, with the appointment of a dedicated consultant in emergency general surgery. The current post holder (NB) has been in place for 18 months, and the job was converted from a locum to a substantive position in January 2012.

There is no physical separation of elective and emergency services at Chelsea and Westminster Hospital, although patients admitted for unscheduled surgery during daylight hours are seen in the acute assessment unit. In addition to the emergency general surgery consultant, the emergency team consists of a specialty training year 3 registrar (currently DK), one core surgical trainee, and two foundation year 1 doctors. The standard working day for all members of the emergency general surgical team is 8 am to 5 pm, during which the team takes all emergency referrals, occasionally delegating more specialist cases to the relevant specialist teams. Out of hours cover is provided in the evenings and nights by a traditional on-call service (staffed by 10 consultant general surgeons, including the consultant in emergency general surgery), with consultant led clinical handovers and patient reviews taking place at 8 am, 4 pm, and 8 pm. A ward round of all the patients under the emergency surgical team’s care takes place twice a day and is led by the emergency surgery registrar or consultant. The figure shows the standard timetable for the emergency surgery consultant at Chelsea and Westminster Hospital.

Timetable for the consultant in emergency general surgery, based on 10 programmed activities

Over 80% of all unscheduled surgery carried out at Chelsea and Westminster Hospital is done in weekday daylight hours by the emergency team in a dedicated NCEPOD (National Confidential Enquiry into Patient Outcome and Death)-standard operating theatre, with little or no disruption to elective services. Surgery after 10 pm is restricted to life and limb threatening conditions and injuries. Over the 12 months from February 2011 the emergency surgical team undertook 421 procedures (box 2), with consultant supervision for each case. An outpatient clinic is run one afternoon a week, allowing the emergency team to follow up patients who have been operated on or who have been discharged with outpatient investigations planned. Excellent access to diagnostic services (radiology and endoscopy) at the hospital facilitates rapid clinical decision making and the avoidance of unnecessary exploratory surgeries.

Box 2: Operative workload of the emergency surgical team over one year

Colorectal

  • 18 colectomies and/or formation of stomas

  • 114 laparoscopic appendicectomies

  • 41 treatments of perianal sepsis

Upper gastrointestinal

  • 29 laparoscopic cholecystectomies (most emergency/hot)

  • 8 perforated ulcers

  • 3 splenectomies (trauma)

General

  • 111 endoscopies (most elective)

  • 20 inguinal hernias (most elective)

  • 11 other hernias

  • 66 various abdominal emergencies, including obstructions and diverticulitis (70% of which were managed laparoscopically)

Setting up a new emergency general surgery service

Other NHS trusts have shown considerable interest in the emergency general surgery service provided at Chelsea and Westminster Hospital. Our advice to hospitals looking to set up a similar service is that a systems based approach is required, rather than simply appointing a sole consultant to run a service. We would recommend that a dedicated team of junior medical staff be available to ensure that optimal care is provided to a group of patients with high levels of morbidity and mortality. Before determining staffing arrangements and support, the hospital should profile its emergency and elective demands so as to plan service provision effectively. One consultant in emergency surgery may not be enough in every hospital.

Given the variable nature of clinical commitments in an emergency service, it is essential that flexibility is built into work plans, as considerable elective commitments lead to disruption of other departmental activities. We suggest that an ethos of teaching, research, and audit is built into the emergency team’s work to create an attractive and constructive working environment.

Training of future consultants in emergency general surgery

No formal training programme exists for junior medical staff looking to take on consultant posts in emergency general surgery, and for the moment trainees will need to undergo conventional training in general surgery. Registrars can, however, tailor their training to become proficient emergency surgeons by gaining wide experience in the different surgical subspecialties, alongside specific knowledge and skills relevant to managing unscheduled surgical admissions. Minimally invasive approaches to managing most general surgery emergencies are now well described, and advanced laparoscopic and endoscopic skills may be beneficial. Time spent training in an intensive care environment may also enhance the care provided to patients, who often require critical care support.

Foundations of a new specialty

With the advent of networked trauma centres in the NHS, we have seen the growth of the subspecialty of trauma surgery. In the future, trauma surgeons are likely to be confined to a small number of regional centres, while emergency general surgeons could be seen in most hospitals accepting unscheduled admissions. If a new specialty of emergency general surgery is to rise to the challenge of improving surgical care, then adequate support and training must be provided. While a formal training curriculum may be many years away, the royal colleges and other professional organisations could provide training courses and other support. Newly appointed emergency general surgeons and those looking to work in this area may also benefit from a network, where best practice can be shared and new ideas discussed.

Competing interests: None declared.

References

  1. Royal College of Surgeons of England. Emergency surgery: standards for unscheduled surgical care. Royal College of Surgeons of England, 2011.
  2. Sorelli P, El-Masry N, Dawson P, Theodorou N. The dedicated emergency surgeon: towards consultant-based acute surgical admissions. Ann R Coll Surg Engl  2008;90:104-8. www.ncbi.nlm.nih.gov/pubmed/1832520.
  3. Royal College of Surgeons. Separating emergency and elective surgical care: recommendations for practice. Royal College of Surgeons, 2007.

Nebil Behar consultant in emergency general surgery
Dominic King clinical lecturer in surgery Department of General Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK

 nebil.behar@chelwest.nhs.uk

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