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Structure, process and outcomes in emergency general surgery DeGirolamo, Kristin 2017

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    Structure, Process, and Outcome in Emergency General Surgery  by  Kristin DeGirolamo  M.D., The University of British Columbia, 2013    A thesis submitted in partial fulfillment of the requirements for the degree of   MASTER OF SCIENCE  in  The Faculty of Graduate and Postdoctoral Studies  (Surgery)   The University of British Columbia (Vancouver)  May 2017  © Kristin DeGirolamo, 2017 	 ii	  Abstract   Background: Dedicated emergency general surgery (EGS) services have been established across North America as a means to bring focus and quality to a large, complex and vulnerable surgical population. The emergence of these services represents a great opportunity to understand and improve emergency surgical care.    Methods: This research programs applies a health systems structure/process/outcomes framework to the study of EGS services in Canada:  1.  Outcome: A systematic review of the effects of an EGS service on patient and non-patient related outcomes 2. Structure: A national cross sectional study of structure and case mix on 14 EGS services  3. Process: Detailed process mapping of a complex EGS condition   Results: 1. Outcomes: Studies found increased daytime and decreased after-hours operating, improved patient transit from ED to OR to home, and decreased length of stay after implementation of an EGS service. The overall trend was higher more diverse case volumes, which improved resident education. Lower complication rates were noticed in the appendicitis and cholecystitis groups.   2. Structure:  Canadian EGS services demonstrated variability in service organization and access to operating rooms. However, a national cross sectional study of EGS patients revealed that all services see diverse case mix and high complexity, and routinely make complex judgments about operative and non-operative care.  3. Process: The processes of care for small bowel obstruction (SBO) patients from the time of presentation to the time of follow-up were highly elaborate and variable in terms of duration. 	 iii	Data visualization strategies were used to identify substantial variability in terms of time to CT scan and time to OR.  Conclusions: The EGS model has been implemented worldwide, and has demonstrated an improvement in timeliness of care, decreased administrative costs, and improved trainee learning. EGS services are well-established in Canada, and poised to identify new opportunities for improved patient care. Process mapping has been successfully integrated into surgical specialties and provides insight into potential areas of performance improvement in EGS.  	 iv	Lay Summary  Emergency General Surgery (EGS) includes any general surgery procedure that is not previously booked on an elective slate and includes multiple organs systems.  Previously this was covered by the “on-call” surgeon but now has organized into teams of surgeons and residents at larger hospitals.  The focus of this thesis is to review the current literature on the impact of ACS services, complete an environmental scan on the current scope of EGS services in Canada and finally, conduct a review of a subset of EGS patients in an effort to find novel ways to introduce quality improvement to our service.                       	 v	Preface  The work described in this thesis started as a casual conversation about Emergency General Surgery (EGS) patients and how their care could be improved.  It grew into talks of uniting EGS surgeons across Canada into a research network, monthly teleconference calls and multiple research projects running through our national group.  This manuscript represents the first chapter in the research efforts from the national group, and the specific efforts driven by the group at Vancouver General Hospital.  This dissertation is original work by the author, Dr. K. DeGirolamo.  This thesis contains the work of 4 articles. Three are currently in press (see details below) and one has been accepted to the American Surgeon.  The chapter (2.2) on the impact of an EGS service on non-patient related outcomes has been accepted to The American Surgeon with publication date pending. The manuscript title is “Processes of Health Care Delivery, Education and Provider Satisfaction in Acute Care Surgery: A Systematic Review.” The primary author, Dr. Kristin DeGirolamo, was responsible for the concept, designing the literature search, reviewing all of the articles and composing the bulk of the manuscript. Co-authors include, Patrick B Murphy2-, Karan D’Souza3, Jacques X. Zhang3, Neil Parry2,4,5, Elliott Haut6, W. Robert Leeper2, 4,5--, Ken Leslie2, Kelly N Vogt2, S. Morad Hameed1,7    Affiliations include: 1. Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada 2. Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada 3. Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada 4. Trauma Program, London Health Sciences Centre, London, ON, Canada 5. Division of Critical Care, London Health Sciences Centre, London, ON, Canada 6. Division of Trauma and Acute Care Surgery, Johns Hopkins University, Baltimore, Maryland, USA 7. Division of Trauma and Acute Care Surgery, Department of Surgery. University of British Columbia, Vancouver, BC, Canada.   	 vi	The chapter (2.1) on the impact of an EGS service on patient related outcomes in currently in press with JACS (Journal of the American College of Surgeons). The manuscript title is “Meta-analysis on the impact of the acute care surgery model of disease specific and patient outcomes in appendicitis and biliary disease”.  Authors were: Patrick B Murphy1, Kristin DeGirolamo2, Theunis Jean Van Zyl3, Laura Allen1, Elliott Haut6, W. Robert Leeper1,4,5, Ken Leslie1, Neil Parry1,4,5, Morad Hameed2,7, Kelly N Vogt1,4  As secondary author Dr. DeGirolamo was responsible for concept, designing the literature search, reviewing all the articles and composing the manuscript. This article has been summarized in section 2.1 and Dr. P Murphy, a co-author, gave permission to report the unpublished data.  Affiliations include: 1. Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada. 2. Department of General Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. 3. Faculty of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada. 4. Trauma Program, London Health Sciences Centre, London, ON, Canada. 5. Division of Critical Care, Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada. 6. Division of Trauma and Acute Care Surgery, Johns Hopkins University, Baltimore, Maryland, USA. 7. Division of Trauma and Acute Care Surgery, Vancouver General Hospital. University of British Columbia, Vancouver, BC, Canada.   Chapter 3, A Day in the Life of Emergency General Surgery in Canada was a prospective data collection done at 14 hospitals across Canada.  Ethics was granted at each of the participating hospital REB and at UBC, UBC CREB Number: H16-01347. The article is currently in press. As primary author, Dr. DeGirolamo was responsible for study design, acting as principle investigator and site lead for VGH.  She also did all the data entry, analysis and composed the majority of the manuscript.   Authors were: K DeGirolamo1, K D’Souza2, S Apte3, C Ball4, S Widder3, S Mueller5, L Gillman6, R Singh7, R Nenshi-Patel8, K Khwaja9, S minor10, M Hameed1,2,11. 	 vii	Affiliations include: 1. Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. 2. Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. 3. Department of Surgery, University of Alberta, Edmonton, AB, Canada. 4. Department of Surgery, University of Calgary, Calgary, AB, Canada. 5. Department of Surgery, University of Saskatchewan, Saskatoon, SK, Canada. 6. Department of Surgery, University of Manitoba, Winnipeg, MB, Canada. 7. Department of Surgery, Northern Ontario School of Medicine, North Bay, ON, Canada. Department of Surgery, McMaster University, Hamilton, ON, Canada. 9. Department of Surgery, McGill University, Montreal, QC, Canada. Department of Surgery, Dalhousie University, Halifax, NS, Canada. 11. Department of Trauma Services, Vancouver General Hospital, Vancouver, BC, Canada.     Chapter 4, on the project “Processes Mapping as a Framework for Performance Improvement in Emergency General Surgery” is in press with the Canadian Journal of Surgery. Data was provided by Vancouver General Hospital Department of Surgery NSQIP office for the SBO pilot project.  The supervising committee for this project consisted of Dr. Morad Hameed (as the Principal Investigator), Drs. Naisan Garraway, Dr. Emilie Joos, Dr. Chad KimSing, and Dr. Patrick McLaughlin as co-investigators.  Under the supervision of the research committee, Dr. DeGirolamo was responsible for formulating the research objectives, study design, obtaining UBC ethics approval, data collection, data analysis and writing the manuscript. Mr. Markus Zurberg (Department of Clinical Quality and Safety) provided the cohort of SBO patients and education around how NSQIP is used within the department of Surgery. Ethics approval was obtained from the UBC Clinical Ethics Review Board for the SBO study component of this manuscript. (UBC CREB No. H15-03023). Authors were  Kristin DeGirolamo1, Karan D’Souza2, William Hall3, Emilie Joos1,2,4, Naisan Garraway1,2.4, Chad Kim Sing2,5, Patrick McLaughlin2,6, and S. Morad Hameed1,2,4.   As the primary author, Dr. DeGirolamo was responsible concept, ethics, data collection and manuscript writing.   	 viii	Affiliations include: (1) Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. (2) Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. (3) Centre for Clinical Epidemiology and Evaluation, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada. (4) Division of Trauma and Acute Care Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada. (5) Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada. (6) Department of Radiology, University of British Columbia, Vancouver, BC, Canada.                        	 ix	Table of contents Abstract……………………………………………………………………………………………ii Lay Summary ……………………………………………………………………………….……iv Preface ………………………………………………………………………………………...…..v Table of contents…………………………………………………………………………...……..ix List of Tables ……………………………………………………………………………….……xi List of figures……………….……………………………………………………………..…… xiii List of Abbreviations…………………………………………………………………………....xiv Acknowledgements ……………………………………………………………………………...xv Dedication……………………………………………………………………………………….xvi Chapter 1: Introduction……..…………….………………………………………………….…1 1.1 Background ………………………………………………………………………...…1 1.2 Overall Project Hypothesis……………………………………………………………3 1.3 Overall Project Objective…………………………………....………………………...3 Chapter 2: Outcomes in EGS – Systematic reviews of clinical and non-clinical effects of EGS service implementation……………………………………………………………….……4 2.1 Meta analysis of the impact of an EGS service implementation on clinical                                                                                   outcomes in appendicitis and cholecystitis……………………..…………………………4 2.2 Systematic Review of the impact of EGS service implementation on clinical process and non clinical outcomes…………………………………………………………..……15 Chapter 3: Structure of EGS Services: A day in the life of Emergency General Surgery in Canada…………………………………………………………………………………………..32 Chapter 4: Process Mapping as a framework for performance improvement in Emergency General Surgery………..……………………………………………………………………….46  4.1 Background of Process Mapping…………………………………………...…….….46  4.2 Methods……………………………………………………………….....….………..47   4.2.1 Study Design………………………………………………………….……47   4.2.2 Inclusion and Exclusion Criteria ……………………………………..……47   4.2.3 Data Analysis………………………………………………………...…….48  4.3 Results…………………………………………………………………………..……48  4.4 Discussion……………………………………………………………………………54 	 x	 4.5 Limitations………………………………………………………………..………….55    4.6 Conclusions…………………………………………………………….…………….56 Chapter 5: Future Directions……………..……………………………………………………57 Bibliography…………………………………………………………………………………….59 Appendix 1. Key Search Terms……………………………………………………..…………68                           	 xi	List of Tables  Chapter 2.1 Table 1 – Characteristics of included studies………………………………………………...…...7 Table 2 – Design of EGS models in included studies…………………………….……………...12  Chapter 2.2 Table 3 – Quality Assessment of Studies using NOS and EPIQ rating processes………………25 Table 4 – Description of Included EGS Models…………………………………………………27 Table 5 – Hospital Delivery Flow Efficiency Outcomes……………...…………………………29 Table 6 – Overall Hospital Length of Stay (LOS) - reported in days……………………………29 Table 7 – Emergency Department (ED) Length of Stay – reported in hours……………………29 Table 8 – Time from Ed to Operating Room (OR)/Surgery – reported in hours………………..29 Table 9 – Surgeries performed during Day-time hours – reported in %.......................................30  Chapter 3  Table 10 – Description of EGS service structures and processes……….…….…………………40 Table 11 – Cohorts of EGS patients by hospital services across Canada……….……………….41  Table 12 – Summary of operative and non-operative management of EGS patients by hospital services across Canada…………………………………………………………….……………..41 Table 13 – Age, sex and comorbidities of EGS patients by hospital……………….……………42 Table 14 – Case mix and resource utilization as reflected by duration of stay at the time of the study…………………………………………………………………….………………………..42  Chapter 4  Table 15 – Patient Demographics for Cohorts of Operative and Conservative Management of Small Bowel Obstruction (SBO) Patients………………………………………………………..49 Table 16 – Mean Process Interval Outcomes for Conservative Management of Small Bowel Obstruction (SBO) Patients………………………………………………..……………………..50 Table 17 – Mean Process Interval Outcomes for Operative Management of Small Bowel Obstruction (SBO) Patients…………………………...………………………………………….51 	 xii	Table 18 – Arrival to OR bases on Priority Levels in Operative Management of Small Bowel Obstruction (SBO) Patients…………………………………………...………………………….52                              	 xiii	List of Figures  Ch. 2.1  Figure 1. PRISMA Flowchart of studies included in the review with reason for exclusion…….14  Ch. 2.2  Figure 2. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA).….31  Chapter 3 Figure 3 – Map of Canada with site descriptions………………….……………………….……39 Figure 4 – Bar-graph of operative vs non-operative totals per site……...…….……..………….43 Figure 5 – A Day in the Life of Acute Care Surgery In Canada Summary Data Collection Form…………………………………………………………………………….………………..44 Figure 6 – A Day in the Life of Acute Care Surgery In Canada Patient Demographic Form.......45   Chapter 4 Figure 7 – Process Map…………………………………………………………………....……..53               	 xiv	List of Abbreviations  VGH Vancouver General Hospital UBC University of British Columbia ACS NSQIP American College of Surgeons – National Surgical Quality Improvement Program EQIP Emergency Surgery Quality Improvement Program MRN Medical Record Number SSI Surgical Site Infection MI Myocardial Infarction ACS Acute Care Surgery EGS Emergency General Surgery OR Operating Room SBO Small Bowel Obstruction CT Computed Tomography JACS Journal of the American College of Surgeons NOS Newcastle Ottawa Scale EPIQ Evidence-based Practice for Improving Quality LOS Length of Stay             	 xv	Acknowledgments   For Dr. Alice Mui, a constant support and believer in my research.  You have provided a constant support system in the form of last minute accepting me into your master’s program, finding funding for my tuition and conferences and encouraging me to participate in multiple local research competitions. Thank you.  For Dr. Morad Hameed, the driver of all of this research.  You constantly push me to think more, do more, achieve more and above all be passionately committed to improving the care of patients served by the EGS service at VGH.  I will be forever grateful for how your mentorship over the last 2 years has helped me develop my research skills and (hopefully!) set me up for a successful career as an EGS surgeon. Thank you.                    	 xvi	Dedication  For Kassem and Hassan, my constant support system and inspiration. This work would not have been possible without Hassan and his dedication to my career.  Hassan, you always ask how you can be more helpful, more involved, always asking what I need to do to improve my future plans and never stop putting Kas and I first.  I truly did choose an equal partner and am so lucky.		 1	Chapter 1 – Introduction  1.1 Background  In the last decade, many centers providing acute general surgery coverage have transitioned from a traditional 24-hr call model to a dedicated emergency general surgery (EGS) model. Many differing structures of such services have been described. The most common design of a dedicated EGS team is a “surgeon of the week” model where a single surgeon suspends his or her elective practice for 7 days and instead manages a team of house staff and/or ancillary health professionals in the management of emergency and in-patient consults for acutely ill general surgery patients. Typical coverage is 7 am to 5 pm on weekdays and a full weekend of coverage. Week nights are covered by other general surgeon staff with dedicated hand-over and transfer of care each morning to the consultant of the week. Some models include dedicated day-time emergency operative time.1–3  The EGS model has many perceived benefits for patient care and disease specific outcomes such as efficient care delivery, shorter time to decision for operation, more day-time operations, reduced peri-operative complications and decreased length of stay.1,2,4–6 Surgeon satisfaction and resident/fellow learning can also be positively impacted.7,8 In the United States this model has amalgamated trauma surgery and emergency surgery into one discipline at many centers to coordinate care of complex emergency general surgery patients, but also to account for the increasing non-operative nature of trauma care.9  A recent meta-analysis evaluated the literature surrounding patient and disease specific outcomes before and after implementation of an EGS model.10 This review was, however, limited by strict inclusion criteria and methodological issues. Another systematic review had a broad scope in determining the structural factors of EGS models but similarly a number of important references were not included.11     	 2	A comprehensive framework for EGS research  Dr. Avedis Donabedian, a Lebanese physician, famously started analyzing health services and quality improvement.  The Donabedian model is named after his lifetime of work into evaluating the quality of healthcare in terms of 3 categories: structure, process and outcomes.12  Structure is evaluated by looking at every context in which care is delivered.  This includes buildings, finance and staff.  Process is how the care is delivered to patients. Outcomes are any product of this system and include patient related outcomes (ex: morbidity and mortality) and non patient related outcomes (ex: cost efficiency, resident learning, quality improvement projects).12   The overall theme for this thesis is the application of the Donabedian model to define the impact of EGS services, characterize EGS patients and systems of care in Canada, and use a representative cohort of EGS patients (small bowel obstruction (SBO)) to test process mapping as a way to identify areas of quality improvement. We will explore the opportunities that these new systems present to elucidate (and therefore improve) the complex processes of emergency surgical care. This dissertation aims to answer the following research questions:  1. How does implementing an EGS service affect appendicitis and cholecystitis outcomes? 2. How does implementing an EGS service affect non-patient related outcomes? 3. What is the current state of EGS services in Canada, with respect to structure and case mix?  4. Do EGS services offer new opportunities to understand and improve the process of emergency surgical care?         	 3	1.2. Overall project hypothesis  We hypothesize that EGS services represent a promising health systems approach to a large and complex surgical population, and that, as these services mature, detailed assessments of their structures, processes and outcomes, including process mapping, will lend unprecedented insights about performance improvement.   1.3 Overall project objective  The overall objective of this dissertation is to highlight the complexity of EGS, report on what is already known about the impact of EGS services and apply the methodology of process mapping to a cohort of SBO patients to identify potential areas for quality improvement.     	 4	Chapter 2: Outcomes in EGS – Systematic reviews of clinical and non-clinical effects of EGS service implementation  2.1 Meta-analysis of the impact of EGS service implementation on clinical outcomes in appendicitis and cholecystitis   Background  The emergency general surgery (EGS) model was developed to acknowledge the complexity of a traditionally fractured emergency general surgery patient population; however there are variations in the design of EGS service models. Prior to being able to apply more specific quality improvement measures we wanted to first review the literature for effect of EGS services on patient outcomes. This meta-analysis analyzes the impact of different EGS models on the outcomes for appendicitis and biliary disease.   Methods  A joint literature search between Western Ontario and UBC was undertaken to review what the literature has reported on the effects of the implementation of an EGS service. A systematic English language search of major databases was conducted. Two independent reviewers then used the Newcastle Ottawa Scale (NOS) and EPIQ methodology to analyze the effects of an EGS service on patients with cholecystitis and appendicitis.    Results  We found that most papers described the effects of an EGS service on patient outcomes, specifically those patients with appendicitis and biliary disease.  The search returned 1827 studies after removal of duplicates, and after applying the inclusion/exclusions criteria 357 articles underwent full text review (see Figure 1). Of the reviewed articles 48 studies were identified as having met inclusion criteria, with reasons for exclusion of the remaining studies 	 5	shown in the PRISMA diagram (Figure 1). Of the 48 articles, 25 contained data on outcomes for appendicitis and/or biliary disease, and are outlined in Table 1.  Appendicitis and Biliary Disease Results  The proportion of negative appendectomies was no different after implementation of an EGS model (OR 1.09, 95% CI 0.91,1.31). Perforated or ruptured appendicitis was no different in the Pre-EGS and Post-EGS period (OR 0.85, 95% CI 0.63,1.14). For both appendicitis and biliary disease there was a significant difference in complication rates, with fewer complications in the Post-EGS period (OR 0.65, 95% CI 0.49,0.86, I2 = 45%; OR 0.50, 95% CI 0.38, 0.65; I2 = 2). The use of a laparoscopic approach was significantly greater in the Post-EGS period (OR 2.59, 95% CI 1.95,3.44; OR 1.4, 95% CI 0.83, 2.37) and there was no difference in the rate of conversion to open (OR 0.6, 95% CI 0.31,1.14; OR 0.74, 95% CI 0.47,1.10). After-hours operating was not statistically different between periods (OR 0.81, 95% CI 0.55, 1.18; OR 0.5, 95% CI 0.16, 1.57). Length of stay was on average 0.5 days shorter in the Post-EGS period (95% CI -0.81, -0.20) for appendicitis and 0.73 days shorter in the Post-EGS period (95% CI -0.1.36, -0.09) for biliary disease. This effect was reduced, but still significant, to 0.2 days when considering only appendicitis studies with dedicated theater time (95% CI -0.29, -0.03, I2 = 0%). This finding may initially come off as insignificant, however if you consider the ubiquity of these diseases, these small improvements do contribute a significant amount of cost and system resource savings.  The time to arrival in the OR from the ED was on average 2.6 hours shorter in the Post-EGS period (95% CI -4.41, -0.86) with significant heterogeneity (I2 = 94%) for appendicitis and 6.95 hours shorter in the Post-EGS period (95% CI -10.25, -3.65) without significant heterogeneity (I2 = 8%) for biliary disease. Sensitivity analysis including appendicitis with dedicated OR time could not account for this heterogeneity (I2 = 84%) and did not yield a significant result (-0.85 hours; 95% CI -2.98, 1.29).   	 6	All reporting studies for biliary disease demonstrated an increase in the number of patients receiving early definitive care (< 72 hrs) and an increase in the rate of index operative management. This is key in reducing the multiple ER visits that patients with biliary disease likely have before definitive management of their gallbladder disease.  Discussion  The introduction of an EGS model of care appears to be associated with improved outcomes following admission for appendicitis and biliary disease. There is also a clear effect of dedicated daytime ORs within this model of care for appendectomy. The results of our meta-analysis suggest a reduction in complications, length of stay, time to operation and an increased use of laparoscopy and an increase in the early definitive management with cholecystectomy after the addition of an EGS model. Dedicated day-time operating theater access seems to impact the effect size of the studied outcome measures, particularly with respect to afterhours operating in appendicitis with a predictable decrease only in those studies with dedicated daytime ORs. We unexpectedly found an increase in perforated appendicitis in EGS models with dedicated daytime ORs; however, this was not associated with a documented increase in overall complication rate.    Our meta-analysis demonstrates benefits to patients and likely to the healthcare system by transitioning from a traditional general surgery call model to an EGS model of care. Our comprehensive search strategy and transparency provide evidence for surgeons and hospitals to adopt this model of care, particularly a model with dedicated emergency daytime operating time. Our results suggest potential quality indicators that are achievable with an EGS service such as timeliness to operation.   Future studies on EGS models of care should be prospective, both before and after implementation, if possible, and should clearly outline the design of the service and define complications and other outcome measures. Furthermore, while the studies considered in this meta-analysis provide a strong justification for the implementation of dedicated EGS service structures for 2 common EGS diagnoses, the next generation of EGS research should examine the effect of EGS services on more acute, complex and resource intensive EGS conditions, which 	 7	often test the limits of modern surgical care, and which may account for the majority of EGS service activity.   Table 1 – Characteristics of included studies Study Year Country Inclusion Criteria Groups N Total Size Age, y, mean +/- SD Male (%) Earley3 2006 USA Appendicitis Pre-EGS Post-EGS 127 167 294 37 ± 15 30 ± 12 62 54 Ekeh13 2008 USA Appendicitis Pre- EGS Post-EGS 273 279 552 37 ± 17 36 ± 16 52 52 Gandy14 2010 Australia Appendicitis Pre-EGS Post-EGS 176 226 402 34 ± NR 33 ± NR 47 54 Qureshi5 2011 Canada Appendicitis Pre-EGS Post-EGS 169 136 305 57 ± 21 57 ± 21 51 49 Poh15 2013 Australia Appendicitis Pre-EGS Post-EGS 256 283 539 32 ± 1 32 ± 1 45 47 Brockman16 2013 Australia Appendicitis Pre-EGS Post-EGS 357 351 708 26 ± NR 26 ± NR 58 50 Pillai17 2013 New Zealand Appendicitis Pre-EGS Post-EGS 875 982 1857 29 (15-100) † 28 (15 -88) † 55 54 	 8	Table 1 – Characteristics of included studies Study Year Country Inclusion Criteria Groups N Total Size Age, y, mean +/- SD Male (%) Lancashire18 2014 Australia Appendicitis Pre-EGS Post-EGS 247 30 548 30 ± 15 29 ± 14 47 44 Beardsley19 2014 Australia Appendicitis Pre-EGS Post-EGS 84 66 150 30 (16-72) † 29 (16-97) † 37 48 Wright20 2014 USA Appendicitis Pre-EGS Post-EGS 526 345 871 38 ± 17 37 ± 15 54 50 Fu21 2014 Taiwan Appendicitis Pre-EGS Post-EGS 146 159 305 41 ± 17 44 ± 29 50 55 Suen22 2014 Australia Appendicitis Pre-EGS Post-EGS 276 399 675 31 ± 14 31 ± 14 56 46 Krouchev23 2014 Canada Appendicitis Pre-EGS Post-EGS 85 84 169 39 (15) 38 (17) 58 52 Agrawal24 2009 UK Early LC for gallstone disease Pre-EGS Post-EGS 45 118 163 44 (23-79) † 47 (18-94) † 18 21 Britt25 2010 USA Biliary tract disease with surgery Pre-EGS Post-EGS 54 132 186 50 ± NR 44 ± NR 37 24 	 9	Table 1 – Characteristics of included studies Study Year Country Inclusion Criteria Groups N Total Size Age, y, mean +/- SD Male (%) Lehane26 2010 Australia AC with surgery Pre-EGS Post-EGS 87 115 202 50 ± 20 47 ± 17 38 30 Lau27 2011 USA AC with surgery Pre-EGS Post-EGS 81 71 152 47 ± NR 46 ± NR 30 28 Pepingco28 2012 Australia AC Pre-EGS Post-EGS 114 157 271 44 (14-85) † 45 (14-94) † 28 39 Cubas29 2012 USA Biliary tract disease with surgery Pre-EGS Post-EGS 51 62 113 38 ± 17 40 ± 19 16 21 Faryniuk30 2013 Canada AC Pre-EGS Post-EGS 5 48 53 NR NR NR NR Stupart31 2013 Australia Cholecystectomy Pre-EGS Post-EGS 96 101 197 NR NR NR NR Lim32 2013 Canada Biliary tract disease with surgery Pre-EGS Post-EGS 72 172 244 50 ± NR 51 ± NR  51 45 	 10	Table 1 – Characteristics of included studies Study Year Country Inclusion Criteria Groups N Total Size Age, y, mean +/- SD Male (%) Wanis7 2014 Canada AC Pre-EGS Post-EGS 55 70 125 47 ± 17 53 ± 17 45 41 O’Mara33 2014 USA Biliary tract disease with surgery Pre-EGS Post-EGS 178 842 1020 NR NR NR NR Michailidou34 2014 USA AC with surgery Pre-EGS Post-EGS 94 234 328 40 ± 15 38 ± 16 34 23 Cubas29 2012 USA Appendicitis Pre-EGS Post-EGS 82 93 175 35 ± 17 34 ± 17 43 55       Biliary tract disease with surgery Pre-EGS Post-EGS 51 62 113 38 ± 17 40 ± 19 16 21 Stupart31 2013 Australia Appendicitis Pre-EGS Post-EGS 305 321 626 NR NR NR NR       Cholecystectomy Pre-EGS Post-EGS 96 101 197 NR NR NR NR Faryniuk30 2013 Canada Appendicitis Pre-EGS Post-EGS 35 152 187 NR NR NR NR       AC Pre-EGS Post-EGS 5 48 53 NR NR NR NR 	 11	Table 1 – Characteristics of included studies Study Year Country Inclusion Criteria Groups N Total Size Age, y, mean +/- SD Male (%) Wanis7 2014 Canada Appendicitis Pre-EGS Post-EGS 142 150 292 37 ± 16 37 ± 18 51 53       AC Pre-EGS Post-EGS 55 70 125 47 ± 17 53 ± 17 45 41 O'Mara33 2014 USA Appendicitis Pre-EGS Post-EGS 196 882 1078 NR NR NR NR       Biliary tract disease with surgery Pre-EGS Post-EGS 178 842 1020 NR NR NR NR EGS = Emergency General Surgery; NR = Not Reported; †Median (range or IQR)               	 12	 Table 2 – Design of EGS models in included studies     Study Characteristic Surgeon of the Week All Surgeons Participate Consultant Led Trauma House Staff Dedicated OR time Defined Period of Service Handover Protocol Specific Remuneration Quality Measures in Place Earley3 - N Y Y Y - - - - - Ekeh13 - N Y Y N - - - - - Gandy14 N - Y - Y Y Y Y - - Qureshi5 Y N Y N Y N Y Y - - Poh15 N - Y - Y Y Y Y Y - Brockman16 - N Y - - Y Y - - - Pillai17 N Y Y - Y Y Y Y N Y Lancashire18 - - Y - Y - - Y - - Beardsley19 N - Y Y Y Y Y - - - Wright20 N Y Y Y Y - Y - N - Fu21 - - Y Y - N - - - - Suen22 Y - Y - - N Y - - - Krouchev23 Y Y Y Y Y N Y Y N Y Agrawal24 Y - Y - - - Y - - - 	 13	Table 2 – Design of EGS models in included studies     Study Characteristic Surgeon of the Week All Surgeons Participate Consultant Led Trauma House Staff Dedicated OR time Defined Period of Service Handover Protocol Specific Remuneration Quality Measures in Place Britt25 N N Y - Y - - - - - Lehane26 N N Y - Y Y Y - - - Lau27 - - Y - Y N - - - - Pepingco28 N - Y - Y - Y - - Y Lim32 Y - Y Y Y Y Y Y - - Michailidou13 - N Y Y Y - - - - - Cubas29 N - Y Y Y - Y - - - Stupart31 - N Y - - Y Y - - - Faryniuk30 Y - Y N - - Y - - - Wanis7 Y - Y - - - Y - - - O'Mara33 N N Y N N - Y Y Y -      	 14	Figure 1. PRISMA Flowchart of studies included in the review with reason for exclusion          	 15	2.2 Systematic review of the impact of EGS service implementation on clinical process and non-clinical outcomes   Background  Upon reviewing the literature around the impact of an EGS service, we noticed a paucity of literature about the processes of delivery of an EGS service, especially in respect to provider satisfaction, systems and resident education. These are key concepts in understanding the true success of an EGS system and help insure staff and hospital administrators believe and support the system.  Methods  The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed for our review (See Figure 2).35 A comprehensive search of PubMed, MEDLINE, EMBASE and the Cochrane Database of Collected Research was performed with the assistance of a trained medical librarian. The search spanned the period from Jan 1, 2005 to June 1, 2015 to identify all English language publications related to modern models of acute care and emergency surgery service delivery. 36 We kept our search terms and keywords broad (see Appendix 1) to ensure a complete review and narrowed the field to explore the specific themes. All titles and abstracts were reviewed independently by two reviewers (PM, KV). Papers selected for full reviews were analyzed by two reviewers (PM, KD) and consensus used for final inclusion. The reference lists of identified studies and reviews were also examined for potentially relevant studies. Authors of conference abstracts were contacted for further information regarding the study and to obtain results. The authors of identified papers that lacked necessary data for inclusion were contacted for further clarification. This review was registered at Prospero (CRD42015025371).37  Study Inclusion  We included studies meeting the following criteria:  	 16	1) Studies comparing outcomes under an EGS model [Post-EGS period] to a period of time without an EGS model [Pre-EGS period]. 2) Event rate or mean and standard deviation for at least one of the following outcomes of interest: flow efficiency, health economics, and trainee education.  Data Extraction  Data were extracted and paper quality assessed by three independent reviewers (KDG, KDS, JZ) and conflicts resolved by a fourth reviewer (PM). We used a standardized data collection form collecting information on study design, inclusion criteria, population demographics, details of the EGS service and sample size. We recorded inclusion criteria as we were evaluating a large spectrum of non-disease specific outcomes. Given the non-standardized criteria and units used by institutions, and for ease of interpretation, the delivery and operational system efficiency outcomes were presented as proportional changes from the pre-EGS period, the baseline, as opposed to absolute values. The flow efficiency outcomes examined included: length of stay (LOS), Emergency Department (ED) length of stay, ED to Operating Room (OR) or Surgery time, and surgeries performed outside day time hours. In terms of outcomes on health economics, they have been relatively underreported, therefore all factors were assessed including: case volume, individual and surgeon remuneration, total collections, and productivity or work resource value units. Lastly, impact on trainee education was reported based on survey data on satisfaction and learning opportunity.  Study Quality Assessment  Study quality for observational studies continues to remain a challenge within systematic reviews and meta-analyses. Based on a systematic review of 194 tools for quality assessment and endorsement from the Cochrane Collaboration we chose to use the Newcastle-Ottawa Scale to assess study quality.38 Quality assessment was completed independently by three reviewers (KDS, KDG, JZ) and discussion with consensus with a fourth for any disagreements (PM). Studies were then assigned a quality rating of ‘Good’, ‘Fair’, or ‘Poor’ based on points in each domain. An important coding understanding with respect to the Newcastle Ottawa score is a lack of statistical 	 17	significance between groups for a potential confounder, such as age or sex, is not sufficient for establishing comparability. The Evidence-Based Practice for Improving Quality (EPIQ) method was also used to grade the quality of included studies based on the level of evidence (1 – Randomized Control Trial to 5 – Studies not directly related to the patient population). Additionally, EPIQ allows for a more subjective overall assessment of the study quality from Good (included most items on the checklist) to Poor (included few items on the checklist).39  Results  Our full-text review of 357 papers revealed 22 relevant studies meeting our inclusion criteria.  All of the 22 studies were retrospective and varied from two to six stars based on the Newcastle-Ottawa scale (Table 3).  For the EPIQ rating 14 of the 22 studies received a rating of Good, and the rest received a rating of Fair (Table 1). The papers originated from North America, Australia, New Zealand and Europe. Themes emerging from this review include: EGS models, hospital flow and efficiency and the economic sustainability, and trainee education.  EGS Models of Service  With no standardized definition of EGS, there is great variability in the literature. Table 4 describes the EGS services that were included in this review.  Unfortunately, many of the studies did not adequately describe their services.  In general, most were surgeon-led and favoured a “surgeon of the week” model that is common to some trauma and ICU services. In this week, the surgeon suspends his or her elective practice to focus on EGS during the day and shares overnight call responsibilities30,40,41Dedicated operating room time was variable among the sites and was reported in 6 studies.17,31,40-44     Another popular model is the creation of an Acute Surgical Unit (ASU), most commonly used in Australia.43,44,45 The ASU is a dedicated ward for acute care surgery patients to be assessed, investigated and treated in a timely manner. The creation of this unit decreased the time to surgery, especially with the addition of a dedicated operating room43. The ASU and protected OR time 	 18	increased cases performed during the day and no change to after-hours operating. The unit also increased frequency of consultant surgeon case review, improved trainee educational experience, and led to improved communication among surgical staff, which was attributed to effective handover.45 Trauma and EGS service models have merged in many US centers due to intrinsic similarities in the nature of the urgent care of multi trauma and emergency general surgery patients, and to improve the operative load of trauma services in an era of increasing non-operative management. The addition of EGS patients to trauma services increases operative volumes of both standard and complex general surgery procedures.46 This combination improves surgeon satisfaction4,7  and with protected EGS time, does not impact surgeons’ elective services in oncology, minimally invasive and colorectal surgery.46  System Performance  Eight papers reported on length of hospital stay5,6,18,30,44,47,48, five papers described emergency department (ED) length of stay5,18,30,44,47, six papers reported on the time lapsed between admission to the ED to the OR/ time to surgery5-7,18,30,40, and five papers reported the percentage of operations performed after-hours4,7,42,45,49 (Table 5-6). In the eight papers that described overall hospital length of stay (LOS), four reported a net decrease, but only one analysis reached statistical significance.47 Decreases in LOS were largely explained by timely assessment by dedicated surgical staff and better access to the OR. Some of these studies further broke down the LOS data into clinically relevant intervals, including time to emergency physician assessment, time to surgical consult request, time to surgical consult, and decision to operate. All four studies that reported on this outcome showed specific and global reductions, which were credited to timely access to dedicated EGS team.5,18,44,47 The efficiency of EGS services was further demonstrated by five included studies reporting a significant decrease in length of time from admission to the OR. Finally, five articles included in our review described a global reduction in the number of cases outside of daytime hours. 5,30,18,42,31    	 19	Finance  Seven studies reported the financial impact of EGS service implementation on stakeholders. Consistently, EGS service implementation significantly increased the overall and daytime operative case volume by 52% on average.50,42,51,52 This increase was often attributed to models that created dedicated ORs or hired additional staff. The change from largely night to daytime operating in a study was reported to decrease the individual case remuneration42; however, in general the increase in volume and productivity led to an overall positive effect on remuneration. Additionally, although there was a downward trend in overall elective cases, it was small and insignificant.42,50 This group of studies also reported significant increases in total collection of revenue by both EGS and elective practices ranging from 11% to 129%.51-53 Improved collections were often closely related to improved productivity as assessed by work resource value units, a regulated measure encompassing services rendered for the purpose of billing (wRVUs). In three studies the mean wRVU or productivity of EGS surgeons increased by 88%50,51,53, one study further described the division of EGS surgeons’ practice showing that they spent more time on non-operative management of patients after EGS service implementation, potentially due to their complex presentations.50  Education and Surgeon Well-Being  Two papers in our review addressed resident education outcomes with the addition of an EGS service. Ahmed et al looked at Accreditation Council for Graduate Medical Education (ACGME) databases to compare resident case numbers before and after the creation of EGS.54 Residents on a 2 month EGS rotation were able to complete 56% of their ACGME laparoscopic requirements. Many of these operations were cholecystectomies and appendectomies, but also included more complex operations. Creation of a dedicated EGS service also protects residents on subspecialty rotations by offloading call requirements to residents who are specifically covering EGS.51  Wood et al demonstrated that residents on subspecialty services covered less call when an EGS service was implemented, increasing resident attendance at academic half day, multidisciplinary rounds, clinics and 	 20	independent reading time.41 Residents surveyed reported an improvement in their work environment despite no change in operating time.51  Discussion  This systematic review demonstrated that the EGS model is associated with improved efficiency, increased timeliness and delivery of care, more resident learning opportunities and improved surgeon satisfaction. A similar meta-analysis from Nagaraja et al.36 had several differences from our systematic review, including: limiting their search to studies assessing acute appendicitis, acute cholecystitis and small bowel obstructions, excluding papers that met our inclusion criteria4,50,31,43-46,48,49,51-53 including papers which did not examine outcomes before and after an EGS model was implemented55; and not addressing the quality of included studies. A more recent review conducted by Chana et al.11 excluded key references comparing the EGS model to the traditional care model despite meeting the described inclusion criteria. Additionally, their review limited financial considerations to cost-savings, and did not comment on trainee education or surgeon well-being.  System Performance  The most common metric used to by studies to determine the impact of the EGS model implementation on health system performance was the overall length of stay (LOS). Evaluation of LOS is versatile as it can be used to assess patient care, quality, financial costs to the system. The majority of studies reported a decrease in the hospital LOS. However, statistically insignificant increases in LOS were attributed to a lack of dedicated OR time, slower model adoption and transition, and back-ups in CT diagnoses or lab values.5,6,48 The trend towards improved efficiency is further supported when the LOS data are stratified into more granular units of time, including, time spent in the emergency department (ED), and time from the ED to the OR. All studies assessing these metrics demonstrated reductions after the EGS model was implemented. Dedicated surgical staffing leads to patients being seen faster, treatment plans being decided on more promptly, patients moving through system more efficiently, and focused and continuous care. This is in stark contrast to the traditional “on call” model, where surgeons taking call add often complex 	 21	emergency surgery patients to their existing elective case load and academic/administrative duties. As such, in the older model, these emergent patients would commonly be seen in between cases or clinics, and operations either disrupted elective slates or were booked at the end of day.6 As overall hospital LOS data depend largely on the entire hospital system, greater reporting of stratified LOS data by key determinants of patient care are needed to effectively assess the impact of the model on the delivery of care. Hence discerning if a metric is impacted by changes attributed to the EGS model or by supporting departments such as pathology and radiology can be determined more conclusively. Changes in the operational efficiency also impact the scheduling of ORs. In the on-call model, surgeons frequently operated after-hours to accommodate the surgical emergencies or bumped elective cases. Studies implementing the EGS model demonstrated a reduction in after-hours operating.4,7,42,45,49, There was also an increase in weekend discharges and therefore patient turnover18,55, which contributed to the increased operative volume and collections. However, these changes are closely related to the availability of dedicated OR time and a fully-staffed 24/7 EGS team, which require an initial capital investment from the institution.  Finance  Assessing the financial impact of EGS service implementation is multifactorial and requires consideration of systemic and individual factors. From an administrative perspective, studies demonstrated that EGS implementation improves the ‘bottom line’ and departmental margins due to increased collections from EGS and elective surgeons.51-53 A considerable rise in the number of cases and physician productivity combined with the savings from reduced LOS and after-hours operating contribute to the increase in collections.4,42,50-52 Implementation of an EGS model undoubtedly has start-up costs, such as the hiring of new staff or creating dedicated OR time and space; however they have been poorly characterized. Nonetheless, one study reported no increase in total admission costs, a more efficient use of resources, and steady usage of EGS-dedicated ORs with non-emergent cases, suggesting at least a neutral cost-benefit analysis.18,42 From the individual surgeon viewpoint, despite the potential for lower reimbursements per case due to increased daytime operating and subsequent reduced compensation from after-hour work, EGS surgeons’ productivity/wRVUs and increased caseloads led to an overall increase in 	 22	billing.6,50-53 The trend of increased collections is also seen among elective surgeons at EGS institutions, suggesting the lack of emergency surgical cases did not significantly impact their remuneration.53 However, despite explicit costs to EGS surgeons, many studies report opportunity costs, including unfavorable call, decreased off-service time to pursue administrative and academic commitments, and lack of manageable lifestyle.6,51-53 Therefore, health systems should consider implementing and re-structuring their EGS models to either mitigate the intangible costs or economically supplement EGS surgeon salaries. Lastly, the economic impact on the system wide delivery shows EGS services tend to have a significantly greater proportion of uninsured patients, suggesting a lower socio-economic status or marginalized population demographic.51,53 Hence, it may suggest the positive impacts of EGS implementation such as timely care, and improved productivity will improve under-served populations care in the long term. Such public health benefits are not limited to a single healthcare model but rather the emergency general surgery population has traditionally received fractured and variable care56. Although the results suggest a positive economic impact, due to the variety of models the evaluation of economic impact is still not clear, and more reporting on the costs of implementation is necessary to confirm future viability and sustainability.  Education and Surgeon Well-Being  An EGS service can improve resident education, especially in light of recent work hour restrictions. Ahmed et al. showed that the implementation of an EGS service improved resident exposure to laparoscopic cases while maintaining a diverse mix of cases.54 Before the EGS service, some cases at major hospitals went uncovered by resident staff, due to the work hour restriction now placed on residents.  This created lost learning opportunities, something that the EGS service has the potential to correct.  Remarkably in this study, the residents were able to fulfill 60% of their ACGME requirements for basic laparoscopic surgery, without changing the number of residents assigned to the service.54 A Canadian study also showed that the creation of an EGS service allowed residents to decrease call requirements, allowing them to have more time to participate on sub specialty services.41 The majority of papers discussed appendectomies and cholecystectomies as the standard EGS cases, however hernia repairs and other laparoscopic cases are noted to add to the operative case 	 23	volumes.46 Increased operative volume and consults also contributes to an improved case mix which is particularly important for surgical trainees rotating on the EGS services.45 The availability of the consultant is beneficial to resident and medical student education around ward management and operative skill.45 General surgery is a diverse specialty, and lack of operative exposure is a fear of many residents.  Switching to the EGS model provides a potential solution to this by increasing case volume and variability, improving resident comfort with emergency general surgery patients and fostering interest in this new field.4  Limitations  A limitation of this review is the lack of direct comparisons that can be drawn between studies due the heterogenic implementations of the EGS model and the inclusion of diverse disease entities. Resources, administrative and financial support all contribute to variable EGS design. Further, most papers poorly described the EGS service. Therefore, it is challenging to recommend a specific EGS model and indeed the success of EGS services likely depends on local buy-in and adapting to local needs. Another limitation is the retrospective nature of included studies, introducing selection and information biases. Lastly, the EGS model has only been proposed and implemented at sites across North America and Australasia within the past decade. As it continues to be a new area of investigation, our review was limited by the availability of studies published in the literature. Additionally, many of the early studies were conducted with small population groups; hence most of the evidence lacks significant statistical power. We do recognize that a randomized control trial is not practical, however large population based trials may be feasible in the future as more centers adopt this model of care.  Future Directions  Within the body of evidence on the EGS model, our review identified a number of areas that require further investigation. Most of the current literature has used appendicitis and cholecystitis patients as the EGS population; however, there exists a gap in including other operative and non-operative emergency general surgical cases that represent a significant portion of the case mix. Additionally, the EGS surgeons’ role in rescuing patients with emergent post-operative 	 24	complications should be further investigated.57 Given that one of the hallmarks of the EGS model is focus and timely consults of potentially surgical patients; there has been no data on patients who have been managed non-operatively. Finally, reporting on the health economics of service implementation, especially on the costs of start-up, impact of surgeon compensation and the role of dedicated daytime OR needs evaluation.  Conclusions  The heterogeneity of EGS models observed in this review, suggests that EGS models are evolving to suit their specific health care environments. Currently, there is a lack of a standardized EGS model and each hospital or region has implemented components based on their needs, resources, and health care system funding and structure. While the differences in the models, along with incomplete descriptions of specific models in some studies, made comparisons challenging, key themes about the impact of EGS service implementation on clinical and educational processes emerged. Initial investments in dedicated operating room (OR) time, hiring of additional staff, devoted on-site surgeon coverage for emergency general surgical conditions, and development of effective handover procedures and trainee education are required for successful service implementation and performance. Such investment may result in greater patient through-put, billings and collections, and surgeon and trainee satisfaction. Furthermore, there is also social return on investment that improves the quality of care for a highly vulnerable patient population.            	 25	Table 3. Quality Assessment of Studies using NOS and EPIQ Rating Processes First Author Year Newcastle-Ottawa Scale Rating EPIQ Ratingb Selection Comparability Outcome Ratinga LOEc Quality Anantha6 2014 **** - ** Fair 3 Good Anantha42 2014 **** - ** Fair 3 Good Anantha40 2014 **** - ** Fair 3 Good Eijsvoogel47 2014 **** - ** Fair 3 Fair Lancashire18 2014 **** - ** Fair 3 Good Wanis7 2014 **** - ** Fair 3 Good Faryniuk30 2013 **** - ** Fair 3 Good Stupart31 2013 **** - ** Fair 3 Good Sweeting51 2013 **** - ** Fair 3 Good Ahmed54 2012 **** - ** Fair 3 Good Hsee43 2012 **** - ** Fair 3 Fair Miller53 2012 * - * Poor 3 Fair Barnes50 2011 *** - ** Fair 3 Fair Qureshi5 2011 **** - ** Fair 3 Good Cox45 2010 **** - ** Fair 3 Fair von Conrady44  2010 **** - ** Fair 3 Good 	 26	Table 3. Quality Assessment of Studies using NOS and EPIQ Rating Processes First Author Year Newcastle-Ottawa Scale Rating EPIQ Ratingb   Selection Comparability Outcome Ratinga LOEc Quality Wood41 2010 *** - ** Fair 3 Good Parasyn4 2009 **** - ** Fair 3 Fair Sorelli49 2008 **** - ** Fair 3 Good Fitzpatrick48 2006 *** - ** Fair 3 Fair Austin46 2005 **** - ** Fair 3 Fair Kaplan53 2005 **** - ** Fair 3 Good   a The Newcastle-Ottawa Scale (NOS) rating correlate to the following levels of risk of bias: Good = High risk of bias; Fair = Moderate Risk of Bias; Poor = High Risk of Bias b Evidence-based Practice for Improving Quality (EPIQ) Process c Level of Evidence (LOE) rated on a scale of 1-5 (1 – RCT or meta-analyses of RCTs; 2 – Studies using concurrent controls without true randomization or meta-analyses of such studies; 3 – Studies using retrospective controls; 4 – Studies without a control group; 5 – Studies not directly related to the specific patient/ population)             	 27	TABLE 4: Description of Included EGS Models First Author Year Characteristics of the EGS Models Weekly Surgeon All Surgeons Participate Trauma House Staff Dedicated OR Time Defined EGS Period Handover Protocol Specific Remuneration Consultant – Led Anantha6 2014 - - - - - - - - - Anantha42 2014 Y Y - Y Y Y - - Y Anantha40 2014 Y Y - Y Y Y - - Y Eijsvoogel47 2014 - - - - - Y - - - Lancashire18 2014 - - - Y N - Y - Y Wanis7 2014 Y - - - - Y - - Y Faryniuk30 2013 Y - - - - - - - Y Stupart31 2013 - - Y - Y Y - - Y Sweeting51 2013 N - - - - Y - Y - Ahmed54 2012 - - - Y - - - - - Hsee43 2012 Y - - Y Y Y Y - Y 	 28	TABLE 4: Description of Included EGS Models First Author Year Characteristics of the EGS Models   Weekly Surgeon All Surgeons Participate Trauma House Staff Dedicated OR Time Defined EGS Period Handover Protocol Specific Remuneration Consultant – Led Miller53 2012 - Y - - - - - - Y Barnes50 2011 - - Y - - Y - - - Qureshi5 2011 Y N N Y N Y Y - Y Cox45 2010 Y Y - Y N Y Y - Y von Conrady44 2010 - - - Y Y Y Y - Y Wood41 2010 Y Y N Y N Y N - Y Parasyn4 2009 - Y - Y Y Y Y - Y Sorelli49 2008 Y - Y - - Y - - Y Fitzpatrick48 2006 - - - - - - - - - Austin46 2005 Y N N Y - Y - - Y Kaplan52 2005 - - N - - - - - - 	 29	Table 5. Hospital Delivery Flow Efficiency Outcomes Table 6. Overall Hospital Length of Stay (LOS) – reported in days First Author Year Pre-EGS Post-EGS % Change p-Value Anantha6 2014 10 (6-17.2)§ 12 (8.5-18.5) § 20 0.16 Lancashire18 2014 2.94 ± 3.25 2.66 ± 2.92 - 9.52 0.274 Eijsvoogel47 2014 4 2 - 50 0.004 Faryniuk30 2013 4.03 3.94 - 2.17 0.91 Stupart31 2013 3.0 (3.0-4.0) § 3.0 (3.0-3.0) § 0 1.3 Qureshi5 2011 2.06 ± 1.2 2.78 ± 2.22 35.15 0.13 von Conrady44 2010 4.2 3 - 28.57 NR Fitzpatrick48 2006 5.75 6.35 10.43 NR Table 7. Emergency Department (ED) Length of Stay – reported in hours First Author Year Pre-EGS Post-EGS % Change p-Value Eijsvoogel47 2014 3.6 (2.2-4.9) § 3.2 (2.2-4.6) § - 11.11 0.414 Lancashire18 2014 9.84 ± 6.48 9.36 ± 5.04 - 4.88 0.385 Qureshi5 2011 17 11.8 - 30.59 0.01 Von Conrady44 2010 3.17 2.05 - 35.33 NR Table 8. Time from ED to Operating Room (OR)/ Surgery - reported in hours First Author Year Pre-EGS Post-EGS % Change p-Value Anantha40 2014 38.4 55.2 43.75 0.40 	 30	Table 8. Time from ED to Operating Room (OR)/ Surgery - reported in hours First Author Year Pre-EGS Post-EGS % Change p-Value Lancashire18 2014 23.14 ± 15.28 21.09 ± 14.58 - 2.53 0.099 Faryniuk30 2013 14.175 7.55 - 46.70 0.10 Stupart31 2013 19 (18-21) § 18 (17-19) § - 5.26 0.033 Qureshi5 2011 8.2 ± 6.8 7.8 ± 6.28 - 4.87 0.40 All reported pre- and post-EGS outcomes were reported as means and standard deviations, when available, with the exception of fields labelled with §, where outcomes were reported as medians and ranges.     Table 9. Surgeries Performed During Day-Time Hours – Reported in % Study Year Pre-EGS Post-EGS p-Value Anantha42 2014 11.0 62.0 < 0.0001 Wanis7 2014 27.4 40.0 < 0.0001 Cox45 2010 57.5 69.9 N/A Parasyn4 2009 64.5 71.7 < 0.0001 Sorelli49 2008 57.0 74.0 < 0.0001       	 31	Figure 2. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA)            	 32	Chapter 3: Structure of EGS Services: A Day in the Life of Emergency General Surgery in Canada  Introduction  General surgical emergencies are common and can account for 25-50% of a general surgeon’s overall workload and 7% of all hospital admissions.56,58 In 2006, the Institute of Medicine named non-trauma surgical emergencies one of the main stressors on emergency departments in the United States.59 Patients facing surgical emergencies are often critically ill and have numerous comorbidities, and timely and comprehensive intervention can often prevent devastating, long term complications.59 Traditionally, on-call surgeons have had to balance emergency surgical care with a busy elective subspecialty services, including rounding on elective patients, seeing clinic patients, and day-time subspecialty operating. Often, surgeons would be expected to continue a subspecialty elective practice the very next day after being on call.  In Canada, there has been a new, grassroots effort to focus and consolidate emergency general surgery (EGS) onto dedicated services. 56,58 EGS services have been implemented with the intent of providing a dedicated, hospital based service specifically for the care of general surgical emergencies.36,60 This allows comprehensive care to be provided while also creating stronger platforms for quality improvement and resource optimization. Limited data has been reported on the overall case mix of these new EGS services, or about their varied structures, processes or outcomes.7,30,42 The emergence of EGS systems represents an opportunity to understand and improve processes of care that serve this complex and resource intensive surgical population. More research is needed on the acuity, complexity and diversity of EGS services and systems, and on the roles that these services play in supporting surgical rescue in acute care health systems.   This study attempts to capture a snapshot at a single point in time of the case mix and workflow of a typical day in emergency general surgery across Canada. We hypothesized that Canadian EGS services face highly acute, complex and diverse case mix and that service models have evolved in unique ways in response to their local contexts.  Shared insights about case mix and 	 33	service delivery will inform the next generation of developments in quality improvement and health system design.  Methods  Study Design  The Canadian Association of General Surgeons formed the Committee on Acute Care Surgery from a group of surgeons providing trauma and EGS care across Canada. The Committee outlined a roadmap for multicenter EGS research, starting with an environmental scan of EGS services across the country. It was felt that such a study would create a strong foundation for future clinical and systems studies in EGS, characterize future participating sites, identify synergies and opportunities for collaboration, help to disseminate best practices, and serve as a gap analysis to identify new research directions.  Many members of the Committee are EGS site leaders, which was a strong advantage for study design, institutional review, and data acquisition.  The protocol for this cross sectional study was approved by the ethics review board at the study lead site (Vancouver General Hospital) and then at each of the participating hospitals.  Service Structure  A survey of EGS service leaders was used to characterize the different services at each hospital. Site leads were asked to complete an excel sheet to describe key features of their EGS services including: the use of a “surgeon of the week” model, the presence of a dedicated EGS service, the availability of protected operating room time for EGS cases, and the ability to use EGS OR time for elective cases. They were also asked if all general and subspecialty surgeons participated, about the involvement of resident coverage, the inclusion of trauma patients, and the existence of a formalized handover process between surgeons at shift change.     	 34	 Cross-Sectional Study of Case Mix  Patients seen by EGS services at participating sites on January 10, 2017 formed the study cohort, and the EGS teams on call from 0700 Jan 10, 2017 to 0700 Jan 11, 2017 were briefed about the protocol. Fourteen hospitals across Canada participated. Study personnel embedded on the services, with supervision by site leaders, collected data prospectively.   The following patients were included in the study: those currently admitted to the EGS service, new consults, and any off-service patients being following by the EGS service between the hours of 0700 Jan 10, 2017 to 0700 Jan 11, 2017.  Off-service was defined as patients admitted to the hospital but not under the direct care of an EGS surgeon. Trauma patients and patients discharged from the EGS service prior to 0700 Jan 10, 2017 were excluded.  Participating sites collected data using standardized case report forms and a summary sheet (Figure 5&6). Data was collected by study personnel at each site under the supervision of the site lead (co-authors of this paper), and the primary author or the site lead did data entry.  All patients currently admitted to the service and new consults were captured. Patient demographic information such as age, sex, comorbidities and previous operations was collected.  All operative and procedural data was collected.  Intraoperative and postoperative complications were also collected. Data was verified with the site leads individually, and all perceived discrepancies and questions were resolved in a second round of communication with all sites.   Results  Emergency General Surgery (EGS) services from 14 hospitals across 6 provinces in Canada participated in this study to document service processes, patient demographics, case diversity and management plans over a single 24-hour period (Figure 3).   	 35	Service Structure  EGS services nationwide differ in the models employed to structure delivery of care (Table 10). All participating sites had a dedicated service with a “surgeon of the week” model where the surgeon suspends their elective practice to focus on EGS patients during the day while sharing overnight call responsibilities. 71% of sites had protected operating room (OR) time, and of those, 70% were permitted to use protected time for elective cases. In contrast to the United States, where trauma and emergency general surgery are often combined in single services61,62, only 29% of Canadian sites included trauma patients under their scope. From an educational perspective, 86% of sites have resident coverage and a formal handover process.   Case Mix  On January 10, 2017, a total of 387 patients were seen across the 14 sites. The services were newly consulted to assess 112 patients, and 68% of these patients were ultimately admitted to be primarily managed by the EGS team. In addition to their responsibilities of evaluating new consults and admissions, the teams also rounded on patients previously under the care of their team. These patients varied in acuity, with 13% being cared for in an intensive care unit (ICU) setting and 7% having open abdomens (Table 11). Within the 24-hours, 53 cases were operated on by EGS surgical teams, 53% were completed laparoscopically. When considering all patients on the EGS lists, 48% of cases were operative (Figure 4). Of the operative cases, 45% were laparoscopic with a 3% conversion rate. There was only 1 intraoperative complication across all sites. Of the remaining total non-operative cases, 57% were managed with antibiotic regimens (Table 12).   The mean age was 59.1 ± 4.9, and on average 52% were male. Patients also required complex medical and surgical management due to their past medical histories with 53% of patients having 1-3 co-morbidities, and 37% having greater than 3 comorbid conditions (Table 13). Patients had a wide range of presenting complaints and final diagnoses that demonstrate the breadth of emergency general surgical conditions evaluated and managed by EGS teams. (Table 14). The most common diagnoses were gall bladder disease (17.6%), gastric/intestinal obstructions 	 36	(14.3%), and appendiceal disease (7.9%). When evaluating the mean days in hospital since admission, neoplasms, pancreatic disease and intestinal obstruction were the top conditions requiring longer average stays in hospital.  Discussion  EGS services are well established across Canada.  This study is a unique snapshot of the complex care that is provided on an average day at 14 hospitals. To our knowledge, this is the first prospective, national study of Canadian EGS services, and, as such, provides a novel look at a large, complex, and resource intensive patient population for which limited reporting exists in the literature .56,61    Service Structure  The development of an EGS services in Canada has largely been a grassroots movement to address the growing complexity of acute care surgery by improving access to care, patient outcomes, and safety while enhancing efficient service delivery, surgeon satisfaction and educational opportunities63. To accomplish these goals, it is apparent from the variation in models adopted at the 14 participating sites, that hospitals have created services structured to meet objectives set based on their local context. The number of surgeons within a department, diversity in the continuum of learners at a site, proximity of tertiary trauma care, and executive administration and financial support are a few potential factors that can impact the organization of an EGS service. The unpredictable pace of emergency surgery has made protected OR time an important part of delivering timely and safe care, and our data suggests there remains a gap in providing allocated time to emergency general surgeons and autonomy in deciding how unused resources are assigned.   Case Mix and Service Activity  The majority of the studies in the EGS literature have focused on processes and outcomes for appendicitis and cholecystitis, which, while accounting for a significant part of the activity of 	 37	EGS services, do not necessarily reflect the breadth, intensity or resource consumption of modern EGS practice.  In our national EGS sample, appendicitis and cholecystitis accounted for only 25% of patients, and only 10% of hospital stay. In contrast, cancer accounted for close to 23% of hospital days, and therefore, EGS service activity.   The study confirms that Canadian EGS services are constantly weighing indications for surgery, and often successfully applying non-operative strategies. Nationally, 51% of patients were managed non-operatively, with MGH site having the highest number of non-operative patients. These patients can often require several resource intensive days in hospital yet their care is not well-documented in the EGS literature. Studies such as ours highlight an opportunity for research that aims to understand and improve the processes and outcomes of care for non-operative EGS patients.  The complexity of EGS may, in part, be reflected by the extent of comorbidities and the frequent need for critical care. Some services reported that up to 72% of their patients had greater than 3 comorbidities. The fact that all of these patients had been considered for, or had actually undergone, major emergency operations, is evidence that EGS services routinely face the heavy responsibilities of assessment, diagnosis, resuscitation and preoperative optimization, operative intervention, and postoperative care along fast timelines for extremely vulnerable patients. Furthermore, the number of EGS patients who are cared for in the ICU, an average of 25.4%, demonstrates the critical status of many of these patients.  This intersection of aggressive surgical care and extreme patient vulnerability is a daily reality on modern EGS services, and an opportunity for multicenter quality improvement, guideline development, and promotion of best practices. There is an urgent need for the next generation of EGS research to explore this intersection more fully.    Research Network and Future Directions  This study was a one-time snapshot of 24-hours of care by EGS services at major Canadian hospitals. It is an observational study that did not capture every hospital with or without a formalized EGS service (mostly due to difficulty in identifying these services and engaging them 	 38	in a national study), and therefore could not provide a comprehensive view of Canadian EGS practice. However, despite its methodological limitations, the study was a proof of concept that it is possible to bring emerging EGS services and patient level insights into a national research network. The rapid completion of this study has shown that national collaboration on research protocol development, coordination of multicenter ethics review board applications, development of data sharing agreements, and shared data analysis, interpretation, and reporting, are highly feasible. The implications of a national EGS research network are great. We have seen in this study that EGS patient populations are large, complex, and resource intensive, and that the structures and processes of EGS care are variable. A national EGS research network will be able to share experiences and define best practices, and will serve as a forum to make these experiences and best practices more universal. The network has already defined a research and quality improvement roadmap, with the next series of studies underway. Future studies will focus on processes of care, complex operative care, determinants of complications and mortality, benchmarks of quality, and surgical education in EGS. Ultimately, it is hoped that this work will lead to a national EGS database and research strategy dedicated to analyzing diversity in the Canadian EGS experience, and to optimizing structure, process and outcome of EGS service delivery.  Conclusion  Canadian EGS services are at the center of Canadian acute care. They are busy intake services for extremely vulnerable patients with a spectrum of complex and acutely life threatening conditions including abdominal sepsis, intestinal obstruction and cancer. They optimize perioperative and operative care along the rapid timelines of acutely time dependent surgical illnesses, and, where possible, they often deploy non-operative approaches as well. They act as rescue services, supporting patient care on other services, and very frequently providing care in intensive care units. They are firmly established as a “strategy for general surgery patients left behind”.56 Ongoing national research collaborations will continue to shed light on the structures, processes and outcomes of these important new services, and will identify new opportunities to improve patient care and system performance.   	 39	Figure 3: Map of Canada with Site Description  	 40	   	 41	    Table 11: Cohorts of emergency general surgery patients by hospital services across Canada Hospital Service EGS List Consults Admits ICU  Pts. (%) Open Abdo. (%) Following  w/o Admit (%) VGH, Vancouver, BC 33 9 7 4 (12.1) 1 (3.0) 4 (12.1) FHH, Calgary, AB 36 15 11 3 (8.3) 1 (2.8) 1 (2.8) SHC, Calgary, AB 24 7 5 3 (12.5) 0 (0.0) 3 (12.5) RGH, Calgary, AB 23 12 9 0 (0.0) 0 (0.0) 7 (30.4) UAH, Edmonton, AB 10 4 3 6 (60.0) 2 (20.0) 5 (50.0) RUH, Saskatoon, SK 10 6 3 0 (0.0) 3 (30.0) 1 (10.0) SPH, Saskatoon, SK 19 10 6 1 (5.3) 0 (0.0) 5 (26.3) SBH, Winnipeg, MB 35 7 7 0 (0.0) 0 (0.0) 0 (0.0) HSC, Winnipeg, MB 28 10 8 10 (35.7) 13 (46.4) 3 (10.7) SJHH, Hamilton, ON 28 4 2 3 (10.7) 0 (0.0) 10 (35.7) NBRH, North Bay, ON 13 8 6 4 (30.8) 0 (0.0) 5 (38.5) RVH, Montreal, QC 12 2 1 3 (25.0) 0 (0.0) 0 (0.0) MGH, Montreal, QC 7 4 2 0 (0.0) 0 (0.0) 1 (14.3) QEH, Halifax, NS 30 14 6 3 (10.0) 2 (6.7)  7 (23.3) TOTAL 308 112 76 40 22 52 Table 12: Summary of operative and non-operative management of EGS patients by hospital services across Canada Hospital Service Lap. ORs Open ORs Total  ORs (%) Converted Cases Total  Non-Op. (%) Non-Op. Pts. w/ Antibiotics VGH, Vancouver, BC 8 17 25 (52.1) 1 23 (47.9) 8 FHH, Calgary, AB 10 9 19 (55.9) 0 15 (44.1) 13 SHC, Calgary, AB 8 6 14 (51.9) 0 13 (48.1) 10 RGH, Calgary, AB 13 3 16 (66.7) 1 8 (33.3) 4 UAH, Edmonton, AB 2 13 15 (60.0) 0 10 (40.0) 5 RUH, Saskatoon, SK 4 3 7 (41.2) 0 10 (58.8) 9 SPH, Saskatoon, SK 6 12 18 (69.2) 1 8 (30.8) 5 SBH, Winnipeg, MB 12 7 19 (54.3) 1 16 (45.7) 11 HSC, Winnipeg, MB 4 12 17 (60.7) 0 11 (39.3) 6 SJHH, Hamilton, ON 9 4 13 (44.8) 1 16 (55.2) 10 NBRH, North Bay, ON 1 6 7 (38.9) 0 11 (61.1) 7 RVH, Montreal, QC 4 2 6 (30.0)  0 14 (70.0) 8 MGH, Montreal, QC 0 1 1 (7.7) 0 12 (92.3) 4 QEH, Halifax, NS 7 12 19 (44.2) 0 24 (55.8) 9 TOTAL 88 107 196 5 191 109 	 42	         Table 13: Age, sex and comorbidities of emergency general surgery patients by hospital  Hospital Service No. of Patients Mean Age Male (%)  >3 Co-Morbidities VGH, Vancouver, BC 48 62.5 44% 35% FHH, Calgary, AB 34 58.2 58% 47% SHC, Calgary, AB 27 56.6 59% 11% RGH, Calgary, AB 24 59.8 43% 7% UAH, Edmonton, AB 25 63.5 68% 72% RUH, Saskatoon, SK 17 50.1 29% 18% SPH, Saskatoon, SK 26 59.1 46% 23% SBH, Winnipeg, MB 35 64.1 66% 46% HSC, Winnipeg, MB 28 51.5 43% 32% SJHH, Hamilton, ON 29 68.1 66% 72% NBRH, North Bay, ON 18 58.5 61% 50% RVH, Montreal, QC 20 57.5 60% 20% MGH, Montreal, QC 13 62.4 38% 23% QEH, Halifax, NS 43 56.1 42% 19% TABLE 14: Case mix and resource utilization as reflected by duration of stay at the time of the study Final Diagnosis No. of Cases (%) Mean Days Since Admission ± SD Gall Bladder Disease 69 (17.6) 5.3 ± 8.0 Intestinal Obstruction 56 (14.3) 11.9 ± 22.1 Appendiceal Disease 31 (7.9) 4.2 ± 8.0 Neoplasms 25 (6.4) 21.7 ± 41.5 Perforations 23 (5.9) 10.7 ± 11.0 Diverticular Disease 19 (4.8) 8.0 ± 12.0 GI Bleeds 18 (4.6) 8.1 ± 13.9 Hernia Disease 16 (4.1) 4.2 ± 4.0 Skin and Soft Tissue Infections 16 (4.1) 6.1 ± 4.3 Pancreatic Disease 15 (3.8) 15.4 ± 24.6 Other # 99 (25.2)  # Includes: Abscesses, Anorectal disease, Breast disease, Sepsis 	 43	Figure 4 Bar graph of operative non-operative totals                         	 44	 Figure 5: Day in the Life of Acute Care Surgery in Canada Summary Data Collection Form    Page 1 of 1 Day in the Life of ACS Data Summary V.2.0 December 14, 2016   Total Number of Consults Seen _____________ Total Number of Patients Admitted _____________ Total Number of Patients under the Care of the Acute Care Surgery (ACS) Service  _____________ Total Number of ICU patients the ACS Service is following _____________ Total Number of Open Abdomen Patients _____________ Total Number of patients the ACS Service is following as Consult ONLY  (i.e. Not Admitted under the ACS Service):  _____________  OPERATIVE DATA:  Total Number of Laparoscopic ORs _____________ Total Number of Open ORs _____________ Total Procedures Completed _____________ Total Intraoperative Complications _____________  NON-OPERATIVE DATA:  Total Number of Patients Admitted with Plans for Non Operative Management _____________ Total Number of Non Operative Patients admitted for Antibiotic Treatment _____________  CASE MIX DATA:  Total Appendicitis Cases _____________ Total Cholecystitis Cases _____________ Total Pancreatitis Cases _____________ Total Intestinal Obstruction Cases _____________ Total Upper GI Bleed Cases _____________ Total Lower GI Bleed Cases _____________ Total Mesenteric Ischemia Cases _____________  Project Principal Investigator S. Morad Hameed, MD MPH FRCSC Vancouver General Hospital – Trauma Services,  855 W 12th Avenue, Vancouver, BC, V5Z 1M9 Fax: (604) 875-5358 For Final Reviewer ONLY: Please check off your institution, ensure no duplicate forms for patients, fill out any missing fields if possible and REMEMBER to redact patient identifiers prior to faxing to Dr. Hameed at (604) 875-5348.   Vancouver General  Royal Columbian  Eagle Ridge  Victoria Gen.  Foothills  Red Deer Regional   University of Alberta  St. Boniface  Health Sciences Centre  Ottawa  Sunnybrook  Toronto General   St. Michael’s  Brampton General  Etobicoke General  McGill University Health Centre   QEII – Halifax Infirmary  SJHH A DAY IN THE LIFE OF ACUTE CARE SURGERY IN CANADA SUMMARY DATA COLLECTION FORM 	 45	Figure 6: A Day in the Life of Acute Care Surgery in Canada Patient Demographic Form     For Final Reviewer ONLY: Please check off your institution, ensure no duplicate forms for patients, fill out any missing fields if possible and REMEMBER to redact patient identifiers prior to faxing to Dr. Hameed at (604) 875-5348.   Vancouver General  Royal Columbian  Eagle Ridge  Victoria Gen.  Foothills  Red Deer Regional   University of Alberta  St. Boniface  Health Sciences Centre  Ottawa  Sunnybrook  Toronto General   St. Michael’s  Brampton General  Etobicoke General  McGill University Health Centre   QEII – Halifax Infirmary  SJHH  A DAY IN THE LIFE OF ACUTE CARE SURGERY IN CANADA Project Principal Investigator S. Morad Hameed, MD MPH FRCSC Vancouver General Hospital – Trauma Services,  855 W 12th Avenue, Vancouver, BC, V5Z 1M9 Fax: (604) 875-5358 PATIENT DEMOGRAPHICS Age: _____________________   Gender:  Male    Female    Other: ___________  Days since admission: _______ Past Medical History/ Co-Morbidities:  Diabetes Mellitus  Smoking  COPD  Myocardial Infarction/ Angina  TIA/ Stroke  Congestive Heart Failure  Previous Abdominal Surgery  Previous VTE or PE  Other: _______________________ Admitting Diagnosis:  Appendicitis  Cholecystitis  Intestinal Obstruction  Mesenteric Ischemia   Abdominal Pain  Skin and Soft Tissue Infections  Other: _______________________  Final Diagnosis (if different from above) _______________________________ MANAGEMENT OF PATIENT  NON-OPERATIVE  OPERATIVE Depending on the management of the patient, you may fill both or just one of the sections. Please choose appropriately. Procedure: _____________________________________ Date of Procedure: ___/____/______ Planned Procedure: ___/____/______             Operative Management of Patient:  Open Abdominal Surgery  Laparoscopic Surgery  Laparoscopic to Open Conversion  Intraoperative Complications (if yes, list below)     ______________________________________________     ______________________________________________   Post-Operative Complications (if yes, list below)     ______________________________________________     ______________________________________________ For the checkboxes that below are ticked, please provide relevant details regarding management  Pain Medications or Other Medications     ____________________________________________     ____________________________________________   Antibiotics     ____________________________________________   Fluids     ____________________________________________   Total Parental Nutrition Ordered   Radiological Interventions     ____________________________________________ COURSE OF TREATMENT Which other medical staff were asked to consult on this patient’s care (Check more than one if applicable)  General Internal Medicine   Gastroenterology  Oncology  Urology  Plastics and Reconstructive Surgery  Other: ______________________________________ Did/ Will this patient be transferred to the Intensive Care Unit during this hospital visit  Yes  No  If yes, please answer the following if applicable:  Patient is or will be mechanically ventilated  Yes  No No. of days patient has been in the ICU: ____________ Discharge Information:  N/A  To Home Page 1 of 1 Day in the Life of Acute Care Surgery V.3.0 December 14, 2016 	 46	Chapter 4: Process Mapping as a Framework for Performance Improvement in Emergency General Surgery  4.1 Background of Process mapping  Emergency general surgery (EGS) conditions are often thought of as being too acute and unpredictable for the development of standardized approaches to QI. However, the surgical literature demonstrates that delays in acute care can cause adverse outcomes and negatively affect the patient and their healthcare experience 64-66 . Effective strategies to measure the process of acute care surgery may open opportunities to improve performance and optimize surgical outcomes in complex and vulnerable surgical populations.   William Edwards Deming revolutionized the manufacturing world and helped to transform Japanese automobile production when he introduced the concept of process mapping.67 Process mapping employs a technique that breaks down complex events into individual processes, and evaluates how these can be made more efficient. The pioneering work of Dr. Deming is epitomized by understanding and learning to manage variation.68 Variation exists in all processes and people, as well as the outcomes that are produced in any given system. In his seminal work, he stratifies the concept of variation into common and special causes.69 Common causes of variance are predictable, expected and natural to the system.68 Identifying common causes is challenging, however these variables generally do not require change strategies, for example, speed and runtime of electronic health records. Alternatively, special causes are new and unanticipated variables that cause variance, and these causes are defects within the system which necessitate improvement, for example, different physician management strategies to clinical presentations.68,70 	 47	 Process mapping in health care involves following patients through their hospital journey and documenting every interaction they have with the hospital system. The method allows providers to notice the small steps prior to management and discharge, and identify areas of high variation and bottlenecks for future improvement. Insights from process mapping have driven large QI advances in Cardiac, ENT and Orthopedic Surgery.71-78   We applied the first three steps of the Six Sigma DMAIC methodology 79, the business world’s equivalent to the PDSA cycle, by measuring and analyzing variation in the patient experience of care to quantify acute care service delivery. Ultimately, our study aims to use process mapping to deconstruct the surgical care of patients presenting to emergency general surgery (EGS) services with acute small bowel obstruction (SBO). To our knowledge, process mapping has not yet been applied in evaluating the delivery of Acute Care Surgery services.   4.2 Methods  4.2.1 Study Design  Ethics approval was granted at our tertiary healthcare centre, VGH.  The American College of Surgeons (ACS) Emergency General Surgery Quality Improvement Program (EQIP) pilot database was used to identify patients presenting to a single, large teaching hospital over a 1-year period (Mar. 1, 2015, to Mar. 1, 2016), for the non-operative or operative management of SBO.   4.2.2 Inclusion and Exclusion Criteria  Inclusion and exclusion criteria were defined by the ACS EQIP pilot.  Inclusion criteria was as follows: diagnosis of SBO by a MD, admission to the hospital or observation unit and imaging 	 48	consistent with SBO. Patients had to be over the age of 18 years and admitted to the General Surgery EGS Service. Exclusion criteria was SBO occurring within 4 weeks of pelvic surgery, SBO occurring secondary to a ventral, inguinal or femoral hernia, Crohn’s disease or SBO occurring in a patient greater than 48 hours after their hospital admission. 4 patients were further excluded from data analysis as upon review of the patient charts as they did not meet NSQIP inclusion criteria.  4.2.3 Data Analysis   Microsoft Excel version 15.18 was used for statistical analysis.   4.3 Results  Small bowel obstruction (SBO) patients at our tertiary Level 1 Trauma Center, Vancouver General Hospital, between March 1, 2015 to April 1, 2016 were stratified into two categories based on their treatment and management. A total of 88 patients were included in our study period, 33 (40%) were managed operatively, while the latter 55 (60%) were managed conservatively. The difference in the mean age between operative and conservative management cohorts (66.3 years ± 17.6 versus 67.5 years ± 17.3; p = 0.747) was not statically significant. Similarly, the comparison between the proportion of males (n = 21 males, 57% versus n = 29 female, 53%; P = 0.700) and medical comorbidities (see Table 1) were also not significant.             	 49	TABLE 15: Patient Demographics for Cohorts of Operative and Conservative Management of Small Bowel Obstruction (SBO) Patients Characteristic Operative Mgmt. (N = 37) Conservative Mgmt. (N = 55) p-value Age, mean ± SD 66.3 ± 17.6 67.5 ± 17.3 0.747 Male, n (%) 21 (56.8%) 29 (52.7%) 0.700 Medical Comorbidities, n (%) Operative Mgmt. (N = 37) Conservative Mgmt. (N = 55) p-value Diabetes Mellitus 4 (10.8%) 4 (7.3%) 0.562 Hypertension 16 (43.2%) 21 (38.2%) 0.633 Acute Renal Failure 0 (0%) 1 (1.8%) 0.415 Congestive Heart Failure 0 (0%) 0 (0%) 1.000 Ascites 0 (0%) 1 (1.8%) 0.415 COPD 0 (0%) 1 (1.8%) 0.415 Smoker 5 (13.5%) 6 (10.9%) 0.708 Disseminated Cancer 1 (2.7%) 6 (10.9%) 0.148 Steroid Use/ Immunosuppression 3 (8.1%) 3 (5.5%) 0.623   Evaluating the mean process intervals and standard deviations of conservatively managed patients in Table 2 demonstrated an unexpectedly high degree of variation in the time interval of care for patients with SBO. The highest amount of variability was in transferring these patients to the ward after admission to the acute care surgery team (259 ± 257 minutes). There was also a longer time and variability associated with time from emergency physician evaluation and CT scan request (112 ± 171 minutes), which remains the mainstay and gold standard of diagnosis in SBO patients. The interval between being seen by an emergency department physician and a consult being sent to the EGS team also experienced higher times and unpredictability. 	 50	 TABLE 16: Mean Process Interval Outcomes for Conservative Management of Small Bowel Obstruction (SBO) Patients Process Interval Measured N Time (mean ± SD, min) Time from arrival to ED to triage 55 11 ± 10 Time from triage to Emerg. MD 55 74 ± 59 Time from Emerg. MD to General Surg. consult initiation 55 198 ± 115 Time from Emerg. MD to CT Request 48 112 ± 171 Time to CT Request to CT Acquisition 49 122 ± 99 Time from General Surg. consult initiation to completion 49 92 ± 79 Time from consult to admission to General Surg. service 49 114 ± 101 Time from admission to General Surg. service to ward 52 259 ± 257 Overall length of stay† 55 83 ± 51   †Reported in hours rather than minutes Note: Denominator varies slightly due to missing data   The process intervals of the operatively managed patients in Table 3 illustrate similar trends of variability. The period of time between evaluation by the ED physician and request of CT scan (121 ± 153 minutes), and between triage and being seen by an ED physician (74 ± 76 minutes) had higher degrees of variation. In addition, the duration of time required to complete the consult (114 ± 167 minutes), to admit the patient to the EGS service after the consult (165 ± 220 minutes), and to arrive to the OR after booking (442 ± 400 minutes) were also identified as areas in the patient’s stay that faced increased standard deviations.    	 51	 TABLE 17: Mean Process Interval Outcomes for Operative Management of Small Bowel Obstruction (SBO) Patients Process Interval Measured N Time (mean ± SD, min) Time from arrival to ED to triage 33 10 ± 14 Time from triage to Emerg. MD 33 74 ± 76 Time from Emerg. MD to General Surg. consult initiation 31 203 ± 102 Time from Emerg. MD to CT Request 30 121 ± 153 Time to CT Request to CT Acquisition 30 142 ± 58 Time from General Surg. consult initiation to completion 30 114 ± 167 Time from consult to admission to General Surg. service 30 165 ± 220 Time from admission to General Surg. service to ward 24 232 ± 170 Time from OR booking to arrival to the OR 33 442 ± 400 Time from OR to ward post-operatively 30 445 ± 266 Overall length of stay† 33 455 ± 884   †Reported in hours rather than minutes Note: Denominator varies slightly due to missing data   In addition to reviewing the journey of surgical patients through the hospital, we also further stratified the time from OR booking to arrival at the OR to assess the efficiency of the acute care service in meeting expected intervals based on the patient’s priority level (Table 4). Patients booked as a E1, our highest priority and meaning they should arrive in the OR within an hour of booking, never arrived at the OR within the expected time limits. The majority of patients were booked as an E2 (arriving at the OR within 8-12 hours of booking) although 69% of these 	 52	patients arrived within the expected interval, there was a higher rate of variability and the mean outside the expected 720 minutes (746 ± 893 minutes). Lastly, the EGS service does have protected OR time, and of the cases completed during these times, 80% were within their booked priority levels time expectations.     TABLE 18: Arrival to OR based on Priority Levels in Operative Management of Small Bowel Obstruction (SBO) Patients  Priority Level N Time from Booking to Arrival at OR (Mean ± SD, min) % of Patients Arriving within Expected Interval E1 (< 60 min from booking) 5 80 ± 17 0.0 % E2 (< 480-720 min from booking) 32 746 ± 893 68.6% E3 (< 4,320 min from booking) 4 2,409 ± 1,277 100.0% Protected Time 5 1,582 ± 2,892 80.0%                	 53	Figure 7:  Sample Process map      	 54	4.4 Discussion  Variation in the clinical setting is unavoidable, and although some variation is expected due to the complexity of cases and individual patient characteristics, there remains differences in productivity, utilization of services and flow.70 Adding capacity and operating rooms only addresses part of this variation, and a deeper assessment of how patients flow through the system can further assist in identifying obstacles and bottlenecks that can be improved. Length of stay and waiting times have become benchmarks of quantifying clinical outcomes, however, this study further stratifies the overall hospital experience into granular periods of time that represent the steps in the clinical management of SBO patients.   In our study and hospital environment, a source of variation in the operative and conservative management strategies of bowel obstruction patients was during the time in the emergency department. Delays in requesting clinical imaging led to increases in mean time and variability in initiating an EGS team consult. Additionally, these delays also led to downstream effects for the EGS team and their ability to assess the patient and make relevant clinical decisions about management and treatment.   A strategy to improve flow in the emergency department would be to add pre-printed orders (PPO) that summarize the evidence-based steps of the initial workup of a suspected case of a SBO. Using the PPO, the emergency physician would be able to start several treatment options and order imaging and laboratory tests critical to management of bowel obstruction patients prior to general surgery consultation. This could potentially streamline and standardize the initial workup thus improving flow through the department, while providing timely and pertinent clinical information to aid in the acute care surgery team’s decision making 80.    Another area of clinical variation was in getting our operatively managed cases to the OR. Although this is a well-established barrier affecting surgeons globally81, we found that most of the high-priority cases were not getting to the OR in the expected intervals due largely to capacity issues. However, the EGS service at our institution has protected OR time that can be used for urgent cases, and our findings show that this time was being used effectively. The 	 55	protected time led to patients receiving their surgeries within the expected interval who may not have if it was not for the dedicated time set aside for the EGS teams. Our sample size for this finding is small, and reflects a need for further data collection and analysis.   The importance of investigating flow and process intervals in patient care is an emerging field in the era of increasing health expenditure and increasing operative and non-operative complexity of patients.81,82  The EQIP pilot program to collect both operative and non-operative patient outcomes allowed for robust data collection. This is the first time such robust data collection strategies have been applied to non-operative patients who are managed by surgical teams. Although there were initial errors that required correction through detailed chart reviews, the program did extend the realm of patients that can be studied to improve quality and safety. From our experience, we discovered that this data was not difficult to collect and eventually led to insights that build efficiencies in the system.   In the future, another practice that can be adopted to track patient care is the use of an electronic platform to document points of care in the patient's journey through the hospital system. With this platform, the general surgery service could have access to real-time data to monitor metrics and evaluate how new QI interventions are working within our system, while simultaneously flagging new areas for intervention.    4.5 Limitations  A limitation of this study is the retrospective nature of data collection, which led to some missing data when reviewing paper medical records. Additionally, even time stamps recorded on the electronic health record for certain points of care were subject to reporting bias, i.e. the order may be given verbally and then entered in at a later time by the physician, leading to a falsely increased time interval. Additionally, our results are specific to our site and should not be generalized to other institutions, however the concept could be easily applied to any other system.  The population we investigated was specific to one condition and part of a pilot EQIP project at our hospital, resulting in a small sample size, particularly our operative group.  Future work will be directed at 	 56	larger groups of surgical patients with the hope of minimizing missing data and generating areas of QI and monitoring, the next steps in the RISE process. We hope our work inspires other centres to follow similar methodologies to discover areas of improvement for surgical patients.    4.6 Conclusions  Quality improvement is the new science of healthcare and our patients expect a “culture of safety” from their healthcare providers.  As surgeons, this represents an exciting time for us to be leaders in safer patient care.  Process mapping is a simple way to evaluate a cohort of patients’ journey through the hospital to identify areas for future interventions as well as track the impact of quality improvement projects. Our cohort small bowel obstruction patients are the first group, to our knowledge, to be analyzed using this method and we hope to expand to more emergency general surgery patients in the future.                     	 57	Chapter 5: Future Directions  All the work described in this thesis is considered just the beginning of research into EGS and quality improvement.  The emerging EGS literature has provided powerful evidence that EGS services improve processes and outcomes for selected diagnoses, and that they have non-clinical advantages as well, including enhancing surgical education, improving surgeon job satisfaction, and potentially for improving the cost effectiveness of emergency surgical care. The Day in the Life study showed us that sophisticated EGS systems have blossomed across Canada, and that they care for complex surgical patients with rapidly responsive and comprehensive service structures that have evolved independently to suit local contexts. We have also seen that the case mix of EGS is broad and without well defined metrics of disease severity and outcomes, and that patients face high levels of comorbidity, suggesting that the impact of EGS conditions on health and health care systems is likely larger than might have been previously thought.   These studies have provided us with both an environmental scan of the current state of EGS, and an analysis of gaps in our understanding, and, perhaps, a roadmap for the next generation of EGS research. More detailed studies of the case mix, disease severity, impact of comorbidity, operative and non-operative interventions, patient outcomes (including long term and patient reported outcomes) are needed in order to identify strategies to further consolidate and advance gains made by the early implementation of EGS services. Individual centers will undoubtedly do this, and we have shown that this work can be done on a larger scale, and with more expertise, in a national collaborative. Multicenter initiatives have the advantage of bringing greater methodological expertise to individual studies, and also of creating networks to disseminate research findings and best practices.   One promising avenue for research and quality improvement is to define complex health care processes in microscopic detail, identifying process variations, and targeting these variations with specific refinements. EGS, with varied and complex time dependent processes, with extremely high stakes with respect to patient outcomes and health care costs, is fertile ground for this type of research. With the current data from our SBO process mapping study, surgeons, emergency physicians and radiologists have begun to meet, for the first time, to address 	 58	bottlenecks and variations in care through the development of pre-printed orders and clinical practice guidelines. Unconventional ideas, such as having SBO consults initiated by radiology, have begun to emerge from more precise, data-driven insights about process.   In summary, we will define outcome measures for EGS and study them prospectively, we will disseminate service structures for new up and coming services and continue to refine them, and we will use Deming’s statistical process control techniques to identify and control variability and quality in highly variable processes.                        	 59	Bibliography  1)     Page DE, Dooreemeah D, Thiruchelvam D. Acute surgical unit: the Australasian experience. ANZ J Surg 2014;84:25–30. 2)     Murphy PB, Paskar D, Parry NG, et al. Implementation of an Acute Care Surgery Service Facilitates Modern Clinical Practice Guidelines for Gallstone Pancreatitis. J Am Coll Surg 2015;222:975–81. 3)     Earley AS, Pryor JP, Kim PK, et al. An acute care surgery model improves outcomes in patients with appendicitis. Ann Surg 2006;244:498–504. 4)     Parasyn AD, Truskett PG, Bennett M, et al. Acute-care surgical service: a change in culture. 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Key Search Terms  “Acute Care Surgery”, “Emergency General Surgery”, “Acute” OR “Urgent” OR “Emergency” AND “Service” OR “Model” AND “Surgical Procedure” OR “Operation” OR “Surgical Department” OR “General Surgery” OR “Operation”, “Team” OR “System” OR “Service” OR “Model” OR “Unit” OR “Ward”, “Acute” OR “Urgent” OR “Emergency” AND “Organization models” OR “Organization efficiency”, “Emergency” OR “Elective” And “Trauma” OR “Emergency Surgery”   	


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