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An Acute Issue - Are ASAUs the Solution?
A LACK OF GENERAL SURGERY SPECIALISTS IS AT THE ROOT OF A POTENTIAL CRISIS IN THE ON-CALL SYSTEM FOR ACUTE SURGICAL CARE. PROFESSOR PAUL RIDGWAY FRCSI EXPLAINS HOW ASAUs ARE PART OF THE SOLUTION
The trend in Ireland and Europe towards sub-specialism means that most surgeons now identify themselves by their sub-specialty interest rather than as General Surgeons. But the reality is that General Surgery accounts for the majority of acute surgical admissions across Ireland every day, with most patients operated on by surgical on-call teams doing emergency work on top of their elective work, a system that leads to delays and ineffciencies in emergency care and has a knock-on impact on elective procedures.
“As surgery pathways have become more complex,” explains Professor Paul Ridgway FRCSI, National Clinical Advisor in General Surgery to the National Clinical Programme for Surgery (NCPS), “surgeons have learned more, yet with a smaller focus. As this referral base has become narrower and narrower, it has led to a lack of generalists. For most of us, the only time we are true General Surgeons is when we are on call for emergencies. In pure numbers terms, most of us see more acute patients than we do elective as these represent the majority of patients under General Surgical Care. We have to balance those two pulls. As General Surgery is a large specialty, accounting for such a large proportion of acute surgical admissions, we need to encourage more surgical trainees to take up General Surgery as their specialty.”
Professor Ridgway believes that the current national on-call system for acute surgical care will soon come under even more negative workforce pressures than currently exist, thanks to a perfect storm currently brewing.
“ There is an ageing workforce doing significant night-time emergency work, and there are sub-specialty (e.g. Breast and Paediatric Surgery) trainees who won’t have the elective volume of abdominal surgery to allow them to be emergency-safe on-call when they reach consultancy. e reality is that a new breast surgeon may feel very uncomfortable with the generality of the work required when on call. And nally there is the increasing importance of work/ life balance which limits the attractiveness of consultant posts involving smaller on-call rotas. e desire for better balance is undoubtedly reasonable, but does add to the recruitment challenge.”
They want their elective specialism, but are not willing to partake in an onerous on-call rota.
“By the time they have completed their fellowship they have spent eight years training. They are then a well-trained, expensive human resource and we have to incentivise them to take up jobs if we want them to come back, or jobs markets overseas will snap them up.”
Professor Paul Ridgeway, FRCSI
National Clinical Advisor in General Surgery to the National Clinical Programme for Surgery (NCPS)
The logical consequence of building bigger rotas is that they exist in fewer places, which segues nicely towards Professor Ridgway’s view that acute care across Ireland needs to be consolidated into a network of Acute Floors comprising an Emergency Department (ED) with allied assessment units such as Acute Surgical Assessment Units (ASAUs) and Acute Medical Assessment Units (AMAUs).
“Building Acute Floors that are fit for purpose with ASAUs that allow for the cohorting of emergency surgical patients will help make General Surgery a specialty people want to go into,” says Professor Ridgway. “ is is not about closing hospitals but making the ones we have better. It’s about delivering the patient to the right place quickly, safely and removing inefficiency.”
Professor Ridgway explains that the way a network operates may mean that a patient is assessed in one hospital but sent on somewhere else for surgery.
“Currently that’s a grace and favour pattern,” he says, “but it should be formalised. The Acute Floor is a modern way of delivery of emergency care where the patient is streamed to the relevant Senior Decision Maker (SDM) in the first instance, allowing efficient and effacacious care.
“In Ireland currently, a key issue is that Acute Floor resources are spread too thin across too many sites. Every night there are 26 acute General Surgical Teams on call for a population of just over ve million people. is is a disproportionately large number given the heterogeneity in the number of patients seen and admitted on each site. e vast majority of these surgical oncall teams are doing the emergency work on top of their normal elective work, leading to delay and ine ciencies in emergency care and a knock-on e ect on elective work.”
A number of ASAUs have been developed and accredited in Ireland over the last ve years. These validation standards were developed by a partnership with the NCPS, Healthcare Pricing Office and Acute Hospitals division of the HSE.
These ASAUs are located in University Hospital Galway, Mater Misericordiae University Hospital, St Luke’s General Hospital, Kilkenny, University Hospital Limerick, Our Lady of Lourdes Hospital, Drogheda, and Cork University Hospital. ese ASAUs have reshaped the way that unscheduled care is delivered to patients who present to hospital with an acute surgical condition.
THE ASAU – 10 GUIDING PRINCIPLES:
1. The primary aim of an ASAU is to deliver Senior Decision Making early in the pathway of selected acute surgical patients.
2. The main quality measures are to reduce Patient Experience Times (PET) and reduce inappropriate admissions thus providing better patient care.
3. Additional gains should include savings in average length of stay (AvLOS), increased patient satisfaction, and decreased time to diagnostics and surgery (if necessary).
4. There should be a critical referral population size in order to deliver cost and other efficiencies.
5. The ASAU should have robust clinical governance.
6. The engagement and ongoing support of the hospital Senior Management Team is important.
7. The ASAU should be in a designated area separate from other units.
8. ASAU patients must have formally agreed access to a dedicated emergency theatre, diagnostics and inpatient beds.
9. A review clinic to facilitate admission avoidance and interface with ambulatory care must be available to ASAU patients.
10. An ASAU may contain bespoke elements to provide for specific local or regional needs.
