Original article

Outcomes in emergency general surgery following the

introduction of a consultant-led unit
R. Shakerian1,2 , B. N. Thomson1,2 , A. Gorelik3 , I. P. Hayes1,2 and A. R. Skandarajah1,2
1 Department

of General Surgical Specialties, 2 Department of Surgery, University of Melbourne, and 3 Melbourne EpiCentre, Centre for Clinical
Epidemiology, Biostatistics and Health Services Research (University of Melbourne and Melbourne Health), The Royal Melbourne Hospital, Parkville,
Victoria, Australia
Correspondence to: Miss R. Shakerian, Department of General Surgical Specialties, Level 2 East, The Royal Melbourne Hospital, 300 Grattan Street,
Parkville, Victoria 3050, Australia (e-mail: shakerian.rose@gmail.com)

Background: Patients presenting with emergency surgical conditions place significant demands on

healthcare services globally. The need to improve emergency surgical care has led to establishment of
consultant-led emergency surgery units. The aim of this study was to determine the effect of a changed
model of service on outcomes.
Methods: A retrospective observational study of all consecutive emergency general surgical admissions
in 20092012 was performed. A 2-year time frame before and after the establishment of the emergency
general surgery (EGS) service was used to determine the number of admissions and operations,
emergency department and hospital length of stay, as well as complication rates.
Results: The study included 7233 acute admissions. The EGS service managed 4468 patients (616
per cent increase) and performed 1804 operations (410 per cent increase). The most common diagnoses during the EGS period included acute appendicitis (532, 119 per cent), biliary disease (361, 81 per cent) and abdominal pain (561, 126 per cent). Appendicectomy (536,
297 per cent), cholecystectomy (239, 132 per cent) and laparotomy (226, 125 per cent) were
the most commonly performed procedures. In the EGS period, time in the emergency department was reduced (from 80 to 60 h; P < 0001), as was length of hospital stay (from 30 to
20 days; P < 0001). The number of complications was reduced by 468 per cent, from 172 (62
per cent) to 147 (33 per cent) (P < 0001), with a 53 per cent reduction in the number of deaths in
the EGS period, from 29 (169 per cent) to seven (8 per cent) (P = 0039).
Conclusion: The establishment of a consultant-led emergency surgical service has been associated with
improved provision of care, resulting in timely management and improved clinical outcomes.
Preliminary results presented to the Annual Scientific Congress of the Royal Australasian College of Surgeons,
Singapore, May 2014
Paper accepted 27 August 2015
Published online 22 October 2015 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9954

Introduction

Emergency general surgical patients form a substantial

proportion of hospital admissions globally1 . In general,
emergency conditions account for more than one-third of
all general surgical admissions2 4 .
The growing and ageing population, rise in complex
and chronic illnesses, and increasing rates of trauma have
been the main contributors to the increased demand for
emergency surgery. Several countries have experienced
an increase in the number of emergency general surgery
(EGS) admissions, with the burden of these conditions
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far exceeding that of many other common public health

problems5 .
In Australia, health services have the additional challenge
of needing to meet government-initiated health targets,
such as elective surgery waiting lists and the National
Emergency Access Target (NEAT) for patient throughput
in emergency departments6 . A proportion of EGS services in Australia have been redesigned, with the aim of
providing timely and efficient emergency care. Although
models of care vary owing to local needs and resources,
the majority of services are consultant-led. A number of
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Outcomes in an emergency general surgery service

studies7 16 have evaluated the impact of new models of

EGS care on patient outcomes. Owing to their prevalence
as common emergency conditions, acute appendicitis and
biliary disease have been the focus of most studies comparing traditional models of care with the new models10,17 21 .
The impact on administrative and clinical outcomes
has been assessed predominantly in the context of these
two conditions, with only a few studies analysing the
impact on the entire cohort of emergency general surgical
admissions.
The aim of the present study was to determine the impact
of an EGS service on the management of all emergency
general surgical patients. Outcomes such as emergency
department and hospital length of stay, as well as the
overall rate of complications, were included. In addition,
the complication rate for patients undergoing emergency
laparotomy was determined.
Methods

The Royal Melbourne Hospital (RMH) is a level 1 trauma

centre that manages about 1800 emergency general surgical patients and 900 patients with major trauma each year.
The Department of General Surgical Specialties manages
all acute trauma and EGS presentations to the hospital.
A retrospective study of all consecutive emergency general surgical admissions between 1 February 2009 and 31
January 2013 was performed using extracted data from the
hospital administrative database as well as the Department
of General Surgical Specialties database. Two 2-year intervals before and after the introduction of the new model of
care in February 2011 were analysed.
The study population consisted of patients admitted
directly from the emergency department, in addition to
those transferred to general surgical units after initial
admission to other units. Inpatient referrals were excluded.
The study was approved by Melbourne Health Office for
Research.

Previous emergency general surgery provision

model
The previous model of emergency care at RMH required
each subspecialty general surgical unit (breast/endocrine,
colorectal, upper gastrointestinal/hepatobiliary, transplant)
to participate in a rotating 24-h emergency on-call roster.
The units registrar was responsible for both elective and
emergency patients. The surgeon was not required on site
and was consulted as required. This model included the
interval from 1 February 2009 to 31 January 2011 in the
present study.
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1727

Establishment of a consultant-led acute surgical

unit
In February 2011, an acute surgical service was established as a consultant-led EGS service. The EGS service
aims to prioritize and improve the care of patients through
early and increased on-site consultant input. The service
aims to facilitate safe and efficient patient management
from the emergency department, ensure rational and judicious use of diagnostics, reduce after-hours surgery, and
minimize the impact on elective surgery. In addition, the
EGS service is designed to increase trainee supervision and
education.
The EGS model of care is led by a consultant on site in
daytime hours (07.00 to 18.00 hours from Monday to Friday; 08.00 to 13.00 hours at weekends), managing all acute
and existing EGS and trauma admissions and supervising
the junior staff of the EGS and trauma teams. The consultants participate actively in handovers, ward rounds, patient
assessment in the emergency department and attending
emergency theatre. The EGS model functions without
a dedicated EGS theatre or a dedicated admission ward.
The service does not benefit from additional radiology
services.

National standards for emergency departments

The introduction of the EGS service at the RMH occurred
1 year before the change from the 8-h rule to the NEAT
4-h rule. Establishment of the EGS service was a component of the hospitals response to the requirement by
2015 for 90 per cent of all emergency patients to be admitted or discharged within 4 h of presentation to the emergency department6 . According to the National Health Performance Authority in Australia, the baseline figure for
patients moving through emergency departments within
4 h ranged from 55 to 71 per cent in 201222 .

Data collection
Retrieved information included patients demographic
data (age, sex, ethnicity) and administrative data (admission and discharge dates, admission and discharge units,
emergency department and hospital length of stay). Clinical data included primary admission diagnosis, major
co-morbidities, surgical interventions, and morbidity and
mortality rates.

Definition of complications
Complications are recorded in the Department of General
Surgical Specialties prospective database, and reviewed
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on a weekly basis at the departments morbidity and

mortality audit. Each complication is captured as an
episode in order to allow for more than one complication
to be recorded for each patient where it is indicated. The
weekly peer review of complications results in grading of
each episode according to the ClavienDindo classification (IV) of surgical complications23 . A further monthly
subaudit committee reviews and finalizes the captured
complications.
In this study, complications following elective procedures requiring acute readmission, and those secondary
to endoscopic and radiological interventions performed by
non-general surgical units, were excluded.
The complication rate was determined for all emergency
general surgical admissions and subsequently for patients
managed exclusively by the general surgical units and the
EGS service (excluding transfers), as well as for patients
undergoing emergency laparotomy. Mortality was defined
as in-hospital complication-related death.

Statistical analysis
A comparison of outcomes between the two time periods
was performed. Differences in patients baseline characteristics and outcomes between the two time frames were
assessed using the 2 test for categorical data and either Students t test or the Wilcoxon rank sum test for continuous
data. Administrative and clinical outcomes were assessed
using multivariable regression analysis with adjustment for
baseline differences between the two groups. All analyses
were performed using Stata 12 (StataCorp LP, College
Station, Texas, USA). P < 0050 was considered statistically
significant.
Results

The study population included a total of 7233 emergency

general surgical admissions (Table 1). Hospital performance
against the NEAT target was found to improve from 682
per cent in 20112012 to 709 per cent in 20122013.

Number of admissions and operations

The increase in acute admissions in the EGS period was
matched by a 410 per cent increase in the total number
of emergency operations performed by the service, from
1279 to 1804 (Table 2). The three most frequent admission
diagnoses in both intervals were acute appendicitis, biliary
disease and non-specific abdominal pain (Table 1). A total of
540 emergency non-trauma laparotomies were performed
in the study period (Table 2).
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R. Shakerian, B. N. Thomson, A. Gorelik, I. P. Hayes and A. R. Skandarajah

Study population characteristics and admission diagnoses

in emergency general surgery

Table 1

Pre-EGS
(n = 2765)

EGS
(n = 4468)

Mean age (years)

516
502
0006
Sex
0071
Male
1352 (489) 2087 (467)
Female
1413 (511) 2381 (533)
Co-morbidities
Hypertension
231 (84)
221 (49) < 0001
Dyslipidaemia
73 (26)
12 (03) < 0001
COPD
26 (09)
44 (10)
0828
Diabetes
94 (34)
257 (58) < 0001
IHD
37 (13)
52 (12)
0536
Atrial fibrillation
90 (33)
116 (26)
0113
Renal impairment
104 (38)
109 (24)
0001
Admission diagnosis
Non-specific abdominal pain
227 (82)
561 (126)
Acute appendicitis
369 (133) 532 (119)
Biliary disease
308 (111) 361 (81)
Perianal/pilonidal abscess
145 (52)
219 (49)
Acute pancreatitis
211 (76)
209 (47)
Diverticular disease/diverticulitis 147 (53)
192 (43)
Intestinal obstruction
227 (82)
179 (40)
Gastritis/colitis/gastroenteritis
92 (33)
164 (37)
Skin and soft tissue infection
65 (24)
152 (34)
Gastrointestinal bleed
100 (36)
127 (28)
Gynaecological
54 (20)
96 (21)
Hernia
105 (38)
85 (19)
Constipation
39 (14)
73 (16)
Urological
36 (13)
46 (10)
Other*
640 (231) 1472 (329)

Values in parentheses are percentages. *Includes a spectrum of conditions

with small admission numbers that have been grouped together. EGS,
emergency general surgery service; COPD, chronic obstructive
pulmonary disease; IHD, ischaemic heart disease. 2 test, except
Students t test.

Effects on length of stay

Establishment of the EGS service resulted in a significant reduction in both emergency department and hospital
lengths of stay. Duration of stay in the emergency department was reduced by 20 h (from 80 (i.q.r. 611) to 60
(58) h; P < 0001). The length of hospital stay was reduced
by 10 day (from 30 (26) to 20 (14) days; P < 0001).
Improvements in length of stay remained significant after
adjustment for patients age, sex and co-morbidities, with
patients in the EGS group having a 113 (95 per cent
c.i. 56 to 171) per cent reduction in hospital and a 215
(185 to 245) per cent reduction in emergency department
length of stay compared with the pre-EGS interval (both
P < 0001).

Complication frequency and severity

The incidence of complication episodes for all emergency
admissions was reduced by 468 per cent, from 172 (62 per
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Table 2

1729

Emergency general surgical procedures

Appendicectomy
Cholecystectomy
Laparotomy
Adhesiolysis small bowel
resection
Colonic resection
Hartmann procedure
Exploratory laparotomy
Repair of gastric/duodenal
perforation/bleeding
Drainage of intra-abdominal
abscess
Other*
Perianal/pilonidal abscess/anal
fistula
Wound debridement/soft tissue
abscess
Hernia repair
Other*

Incidence of complication episodes in patients managed

by general surgical units before and after the establishment of
the emergency general surgery service

Table 3

Pre-EGS
(n = 1279)

EGS
(n = 1804)

368 (288)
164 (128)
314 (246)
87

536 (297)
239 (132)
226 (125)
83

75
23
44
27

45
10
24
14

18

15

40
115 (90)

35
182 (101)

85 (66)

152 (84)

69 (54)
164 (128)

85 (47)
384 (213)

Values in parentheses are percentage of procedures. *Includes a spectrum

of procedures with small numbers that have been grouped together. EGS,
emergency general surgery service.

ClavienDindo grade
I
II
III
IV
V (death)
Non-operative
Postoperative

Pre-EGS (n = 172)

EGS (n = 93)

26 (151)
49 (285)
49 (285)
19 (110)
29 (169)
10
19

20 (22)
30 (32)
29 (31)
7 (8)
7 (8)
2
5

Values in parentheses are percentages. EGS, emergency general surgery

service.

The complication rate following emergency laparotomy

was reduced from 248 per cent (78 of 314) in the pre-EGS
interval to 190 per cent (43 of 226) in the EGS interval (P = 0111). The laparotomy-related mortality rate was
significantly reduced in the EGS cohort, from 23 per cent
(18 of 78) to 12 per cent (5 of 43) (P < 0001).
Specific complications are shown in Table S1 (supporting
information).

Intensive care unit admissions

cent) before to 147 (33 per cent) after establishment of the
EGS service (P < 0001). For patients managed exclusively
by the general surgical units (pre-EGS, 2765; EGS, 3447)
there was a 565 per cent reduction in the incidence of
complication episodes amongst the EGS cohort (from 62
to 27 per cent; P < 0001).
There was no difference in the incidence of grade IIII
complication episodes between the pre-EGS and EGS
cohorts. However, the proportion of grade IV and V complications was reduced significantly, from 279 to 150
per cent (P = 0018), with the greatest reduction in grade
V complications (from 169 to 8 per cent; P = 0039).
This remained significant after the adjustment for type
of surgery (laparotomy, etc.), co-morbidities and intensive
care unit (ICU) admission (grade IV and V complications:
odds ratio 038, 95 per cent c.i. 016 to 093; P = 0033).
The incidence of complication episodes in emergency
patients managed by general surgical units before and after
the establishment of the EGS service are summarized in
Table 3.
The incidence of complications in patients managed
without surgery in the pre-EGS cohort was 13 per cent
(19 of 1486), compared with 10 per cent (16 of 1643)
in the EGS cohort (P = 0430). For those managed surgically, the postoperative complication rate was 120 per cent
(153 of 1279) and 43 per cent (77 of 1804) respectively
(P < 0001).
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The proportion of complication episodes leading to ICU

admission decreased from 110 per cent (19 of 172) in the
pre-EGS interval to 8 per cent (7 of 93) in the EGS period;
this difference was not significant (P = 0360).

Mortality
There was a significant reduction in the number of deaths,
from 29 (169 per cent) of 172 in the pre-EGS period to
seven (8 per cent) of 93 in the EGS period (P = 0039). In
the pre-EGS interval, 18 of the postoperative deaths were
following emergency laparotomy, and one occurred after a
diagnostic laparoscopy. In the EGS interval, all five postoperative deaths were following laparotomy (cardiovascular,
3; ischaemic gut, 1; omental patch leak, 1). Although admission diagnoses were known for all patients who died, the
specific cause of death was documented only for the EGS
cohort. No further additional information (apart from
death) was documented in the pre-EGS database. Postoperative and non-operative deaths are summarized in
Table S2 (supporting information).
Discussion

Despite the significant increase in workload of emergency

surgery, reduced emergency department and hospital lengths of stay were achieved in conjunction with
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R. Shakerian, B. N. Thomson, A. Gorelik, I. P. Hayes and A. R. Skandarajah

reduced complication rates following the establishment

of a consultant-led EGS service. The most common
admission diagnoses reflected the disease spectrum within
EGS reported by others13,24,25 . The most commonly performed operations also reflected the experience of other
emergency surgery units14,25 28 . In the present study, a
reduction in the number of patients admitted with intestinal obstruction was noted to correlate with a reduction in
the number of emergency laparotomies being performed
in the EGS interval.
This study found an increase in admissions for acute
appendicitis, biliary disease, perianal/pilonidal disease,
diverticular disease, and skin and soft tissue infections during the EGS period. The increase in acute admissions has
been well described in both population-based studies5 and
those looking at specific management of acute appendicitis
and acute cholecystitis in the EGS setting10,17,20,21,29,30 .
The number of patients admitted and subsequently discharged with a diagnosis of non-specific abdominal pain
more than doubled following establishment of the acute
service. As the EGS service aims to facilitate flow through
the emergency department, patients with undifferentiated
or non-specific abdominal pain are routinely referred to
the service, accounting for the increase in admissions with
this diagnosis. Non-specific abdominal pain, defined as
acute abdominal pain of less than 7 days duration where
no diagnosis is reached after assessment and investigation,
accounts for 1340 per cent of all surgical admissions with
abdominal pain in the UK31 . Abdominal pain is increasingly being managed by acute surgical units owing to the
time restraints imposed on emergency departments. Similarly, owing to their presentation with abdominal pain as a
primary complaint, patients with gynaecological, urological and gastrointestinal conditions are also increasingly
being referred to the EGS services.
A significant decrease in the duration of hospital stay
was demonstrated in the present study, reflecting the
experience of others11,13,16 . Although EGS services have
led to earlier surgical assessment in the emergency
department12,13,17,19 , this study also found a reduction
in emergency department length of stay.
A number of studies3,32 35 have demonstrated trends
towards emergency patients being older with higher acuity
and multiple co-morbidities and experiencing adverse
outcomes, compared with the elective surgery population.
Patients with emergency surgical conditions do not benefit
from preoperative care and optimization to the same extent
as patients undergoing high-risk elective operations, with
many of the predictors of perioperative morbidity not
being modifiable owing either to their nature (age, sex)
or to the time constraints of the emergency condition

(for example, perforated organ requiring immediate

surgery)36 .
This study showed a significant reduction in complication episodes both in the overall patient population and in
patients managed exclusively by the general surgical units.
The overall morbidity rate of 33 per cent in the
EGS patient cohort is well below the 12247 per
cent rate reported in the literature for the EGS
population11,32,33,37,38 . The overall mortality rate of 8
per cent is within the reported range of 14156 per
cent3,11,32,33,37 . For patients undergoing emergency laparotomy, the overall morbidity and mortality rates in the
EGS cohort were 190 and 12 per cent respectively. The
overall mortality rate in patients having emergency laparotomy has been reported to be approximately 1415 per
cent34,35,39,40 .
ClavienDindo grades IIII are often under-reported,
compared with grade IVV complications41,42 . At RMH,
the surgical audit database was upgraded to coincide with
the introduction of the EGS service. A shift to a real-time
electronic database has enabled accurate and up-to-date
data capture, in particular relating to complication episodes
and to facilitating the hand-over process. It is possible that
the increased consultant involvement in patient management has improved recognition and capture of complication data, as demonstrated by the increased number of
grade IIII complications in the EGS cohort, although this
trend was not statistically significant.
Although this was a retrospective study, the prospective
databases were designed to facilitate data capture and analysis. A further limitation of the study was the exclusion of
patients who were transferred from the EGS service to the
subspecialty general surgical units. This exclusion was necessary, as their surgical care provision had changed from
the consultant-led model back to the traditional model. In
addition, although the impact of the NEAT on duration
of stay in the emergency department needs to be acknowledged when assessing the performance of the EGS service,
it is important to note that there was minimal change in
the 4-h admission rate during the study period. Thus, the
authors believe the observed improvements are unlikely to
be due to the NEAT or other changes occurring as part of
the implementation of the 4-h rule.

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Disclosure

The authors declare no conflict of interest.

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Supporting information

Additional supporting information may be found in the online version of this article:
Table S1 Summary of complication types according to ClavienDindo classification of surgical complications (Word
document)
Table S2 Summary of mortality (Word document)

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BJS 2015; 102: 17261732