The ACS model was defined as a surgical team dedicated to the evaluation and management of urgent and emergent surgical consultations without having concurrent obligations related to the surgeons’ elective practices. The traditional model of care for emergency surgery patients was an “on-call” system which was defined as having a rotating pool of general surgeons who would intermittently take call while continuing with their regularly scheduled clinical obligations[4]. Previous studies have demonstrated the improvement in injury-related mortality and length of stay in hospital systems that use this ACS model[5]. Furthermore, ACS also facilitates the logistics of caring for the acutely ill patient, maintains trauma surgeons’ operative skills, and allows the elective surgeons to pursue an uninterrupted schedule. Despite these theoretical benefits to the hospital and surgical subspecialist, acute care surgeons often experience relatively some problems and dilemmas involved in exploding ED visits, elderly patients and discipline development[6] .In response to this challenge, a special ACS model was developed at a Third Grade Class A hospital in Harbin,Heilongjiang province,China. The key elements were:
* The impetus for the ACS target was the desire by speeding recovery to reduce ED overcrowding and hospital access block in the hope of improving both outcomes for patients and health service efficiency.
* ACS surgeons commit to being available for a 24-hour emergency duty omnibus diebus quaternis, and to lead a team consisting of a senior surgical resident, several junior residents, and medical students. Another teams were on call the other night. There are total four teams including 20 ACS surgeons in our ACS model.
* In this new model, the sub-specialty staff surgeons were available for a 24-hour emergency with ACS surgeons at the same time. It is worth noting that the sub-specialty staff surgeons who on emergency duty do not do elective surgery, but devote themselves to being available in a timely fashion to perform any emergency operation or provide emergency consultation. In our hospital, orthopedics and general surgery involve 14 sub-specialties, each of which is divided into multiple medical teams. Each medical team is responsible for one day’s emergency treatment in turn.
* ACS surgeons are the dominant force in the treatment of emergency patients, and decide which patients need to be admitted to hospital and the departments in which they are admitted (such as ACS unit, general surgery unit, orthopedic surgery unit, etc.).
* In order to ensure the implementation of the ACS, we create a 24-h emergency outpatient surgery unit at our tertiary referral center. Emergency outpatient surgery differed from ambulatory surgery and emergency day-case surgery, as it implies either did not require hospitalization or a LOS less than 24 h, which could include overnight hospitalization. All emergency outpatient procedures are performed by ACS surgeons.
* Setting targets for LOS of ED patients based on triage acuity, disease characteristics and monthly ED visits. ACS surgeons receive additional funds each month contingent on meeting ACS-specific improvements in achieving targets. This is called pay for performance: the “money”.
* Other features include a major effort to improve patients’ ward outflow by transfering some postoperative or alternate level of care patients to rehabilitation wards.
ED overcrowding has been defined as a situation in which demand for acute care exceeds the ability of physicians and nurses to provide timely quality care, which threatens patient health and fosters patient dissatisfaction[7]. Many factors can contribute to overcrowding : preemergency factors that drive demand for emergency services, patients frequently use ED for non-urgent conditions, size/capacity of the ED and its efficiency of processing, and flow out from the ED to the hospital wards[8]. Among these, we think that ED crowding is most commonly due to the boarding of inpatients lacking beds for extended periods–reducing or eliminating this should greatly improve ED efficiency. It’s remarkable that saving 1 to 2 days per treated patient, hospital bed utilization will be reduced by 15%.In many respects, our hospital has noted an increased acuity of ED visits presenting to us. There were 231,229 ED visits; 7,584 surgical emergency patients of these were hospitalization, corresponding to 21 surgical emergency patients were hospitalization every day; 4,100 of these patients were admitted for ACS service between 01 January 2018 and 1 January 2019. With these starling figures, there is no end in sight to today’s health care crisis, and it probably has not reached its pinnacle.
Moreover, more than half of patients were over 55 (52.41%), and 213 patients were 85 years and older in our study(Fig. 2 ). As is known to all, The World Health Organization (WHO) defines an elderly person as one who has a chronological age of 65 years or more. Life expectancy and the proportion of the elderly population are increasing worldwide. The population in China is also aging rapidly. According to the “2018 China Statistical Yearbook Compiled by National Bureau of Statistics of China (http://www.stats.gov.cn/),” people aged 65 and over accounted for 11.4% (158.31 million) of the total population in 2017 in China; by 2030, the population is predicted to be 1.46 billion, and 16% percent of Chinese citizens will be aged 65 and over[9]. Recent research has highlighted the importance of biological not just chronological age. Functional decline and chronic health conditions can appear earlier than 65 years, particularly among individuals who experience health disparities[10]. The increasing rate of serious injury among older adults represents a formidable challenge for geriatric care as elders fare worse in terms of risk of disability, hospital length of stay, and risk of mortality in comparison with younger individuals with similar injuries. For example, Sieling et al found that among the oldest old undergoing surgery for trauma, 8% of the patients experienced at least one medical complication, whereas 5% of the patients experienced multiple complications, including heart arrhythmias requiring stabilization, respiratory failure requiring ventilation, gastrointestinal tract bleeding, and urinary tract infections[11]. The issue of mortality is an important one in emergency surgery, especially in elderly patients. In our study, Multivariate analysis identified age ≧ 65 (p = 0.023; odds ratio, OR = 2.66) is the factor associated with in-hospital mortality. The postoperative mortality increased with age is more pronounced, when stratifying patients by age. What is noteworthy is that there was also a increase in LOS between young and elderly postoperative patients (11.67 ± 9.48 vs 13.95 ± 9.11 p < 0.05). In our ACS model, we reduce ED overcrowding and settle the problem of geriatric emergency patients by transfering some complicated diseases or the oldest old patients to the highly specialized surgical units.
As is known to all, surgeons are more often tending to “organ-specific” surgeon practices(“breast surgeon”;”pancreatic surgeon”;”colorectal surgeon” ; ”gastrointestinal surgeon”). Highly focused specialization in all aspects of medicine is accelerating as the complexities of care increase and the sophisticated demands of patients show no sign of abating. This has led a shift in focus from general surgery with broad spectrum of diseases and surgical techniques. Meanwhile medical specialization is increasingly being managed by minimal-invasive techniques[12]. Overall, the general surgery workforce has followed a trend of increased specialization. The era of the “omnipotent general surgeon” is to an end and in order to improve quality in specific areas many institutions dedicate most of their economic resources to highly specialized surgical units. In our hospital, the general surgery are subdivided by subspecialty expertise into colorectal, hepatic, breast, thyroid, oncology, gastrointestinal, vascular, pancreatic and endoscopic biliary surgery. The orthopedic surgery are subdivided by subspecialty expertise into spine, joint, bone tumour, trauma and hand microsurgery. Indubitability, some complicated or geriatric emergency patients will benefit more from the specialist treatment than ACS.
Though not currently well-described in the literature, many models across the world essentially added EGS services to existing trauma services, creating a hybrid trauma-EGS services. In China, ACS hospitals are concentrated in large academic referral centers. Although past studies have demonstrated improvements in efficacy at such institutions with ACS implementation, most of them appear to the hybrid model. In fact, in most of the world, general surgeons associated to other clinicians in a dedicated team to ACS patients, practice ACS by necessity and not based on specific training in the specialty. Focus on the facts that several models must be created based on patients’ needs and fitted to the local/regional public health requirements. Most surgeons are familiar with the Chinese symbol for learning: Better master one than engage with ten. Compared with this hybrid model, the standard ACS model requires surgeons to acquire more skills, which often involve multiple specialties. This has resulted in heavy pressure on ACS surgeons and no formal ACS specialists in most countries. The danger ACS surgeons (and thereby trauma centers and systems) face is that they may attract few new recruits unless we provide a clear advantage and meaningful purpose to this career choice. So we first came up with this concept of Fast Track Acute Care Surgery (FTACS) through the implementation of this special model. we hope to determine the safety and fast of continuously receiving emergency patients at institutions with FTACS implementation.
Enhanced Recovery after Surgery (ERAS) programmes, also referred to as “fast track”(FT) perioperative care, are evidenced-based protocols designed to standardize and optimize perioperative care in order to reduce surgical trauma, perioperative physiological stress and organ dysfunction (metabolic, endocrine and inflammatory response as well as reduce protein catabolism) related to elective procedures[13]. Nowadays, a systematic review focusing on safety of ERAS for geriatric emergency patients was conducted by Paduraru M et al[14]. Their study demonstrated that ERAS can be safely applied to elderly and emergency patients with a reduction in postoperative complications, hospitalization and readmission rates. Patient compliance was also addressed in a number of the studies reviewed and ranged from 50 to 85%[15][16]. Emergency surgery patients achieved an average level of compliance in comparison to elective surgical patients, again demonstrating that ERAS in emergency surgery is feasible. Certainly, one of the most challenging aspects of FTACS improvement is the selection of appropriate patient. In our new model, the initial vision is to triage some emergency patients and keep those patients suitable for rapid rehabilitation treatment in ACS. However, several challenges and opportunities associated with the implementation of this model have yet to be evaluated and overcome before a wider implementation. Moreover, more research is still needed in relation to identifying which elements of ERAS have greater impact on emergency surgery patients and whether independent impact plays a more significant role.
This study has a few limitations. First, it considered only one specialty care unit and ED at the same hospital, so similar studies in other settings might be conducted before forming broad conclusions. Other limitations include that this was a single center study at a large academic medical center in a metropolitan area with a large number of affiliated specialty services. The percentage of patients is likely higher than it would be in a community hospital. Finally, it is generally believed that both preoperative medical conditions and postoperative complications are important determinants for postoperative short- and long-term mortality of emergency patients. In our statistical analysis, we did not provide the details evidence indicates that intraoperative massive blood loss, blood transfusion, adverse cardiovascular events and total fluid volume are associated significantly with increased risks of postoperative mortality after emergency surgery. Our study does also not evaluate for differences in rates of operative, conservative, or interventional management, which could have large impacts on lengths of stay and outcomes.