The provision of 24/7 emergency surgery should cease in a large number of hospitals in order to provide a safer service for patients and a more attractive one for staff, a new report recommends.
It proposes the creation of networks of hospitals in each region to provide emergency surgical care, saying this would deliver a higher-quality service to patients, preserve access to senior surgical decision-makers and create a better working environment for staff.
Acute surgical assessment units (ASAUs) should be provided in every hospital to receive emergencies; this would allow a reduction in the number of hospitals providing out-of-hours emergency general surgery, according to the report from the Royal College of Surgeons in Ireland.
At present, 25 hospitals are providing round-the-clock emergency surgery but due to staffing challenges there is a heavy reliance on expensive locum staff and doctors on the general register acting as specialists. Surgeons often have to work every third or fourth night, making it difficult to attract suitably qualified staff.
“The current situation is not sustainable,” RCSI vice-president Prof Deborah McNamara told The Irish Times. “At present, we cannot staff 25 surgical centres operating 24/7 with permanent, properly trained staff.”
Prof McNamara said she did not have a “fixed view” on how many centres should cease providing emergency surgery around the clock and suggested this decision could be made by proposed new regional health areas when they are established.
There are currently six ASAUs in hospitals, providing routine surgeries such as gallstone or appendix removal. Prof McNamara says their range of activity could be expanded to include urology procedures and plastic surgery.
Fewer hospitals should provide emergency surgery on a 24/7 basis, the Surgery for Ireland report says. “Access to emergency surgery can be preserved in a large number of hospitals, for example from 8am to 8pm, without the requirement for availability of overnight surgical activities.”
“Ensuring that surgeons are members of well-functioning emergency surgery networks offers the best chance of addressing the recruitment and retention challenges that are currently experienced by many of our hospitals.”
Advances in technology give surgeons more options than ever before, Prof McNamara pointed out. At the same time, greater life expectancy means emergency surgery patients are more complex.
“The majority of emergency operations can be delivered safely in most hospitals but the current system, with onerous on-call rotas and low volumes of high-risk cases in many hospitals, makes it difficult for the more complex emergency patients to receive the care they need.”
The report is critical of the “unprecedented and unacceptable” waiting times for patients needing scheduled surgery and says this strongly indicates a lack of resources for surgery.
But making necessary changes to unscheduled services must not reduce the number of hospitals currently performing surgery: “In fact, delivering out-of-hours unscheduled surgery at fewer hospital sites is critical to enable our health service to address the unmet need for scheduled surgery.”
Emergency surgery is safest when performed during normal working hours by fully-trained staff and where sufficient volumes of surgery are performed to maintain expertise, it points out.
It proposes a networked system of emergency surgical care delivered “as near as possible to the patient’s home”. Each surgery network should comprise injury units, ASAUs for straightforward cases, emergency surgery units and emergency surgery centres, supported by an elective hospital.
The emergency surgery centres would operate 24/7 and draw on round-the-clock radiology and endoscopy services. The emergency surgery units would be staffed to provide surgery for eight to 12 hours a day, either five or seven days a week, depending on their location and caseload.
The current system, where surgeons are not exclusively responsible for emergency surgery as part of their normal working week, pays insufficient attention to the needs of older patients with complex needs, according to the report.
“The networked approach that is described will deliver a higher-quality service to patients and will preserve access across the country to senior surgical decision-makers while creating a working environment that is optimal for training, recruitment and retention of staff.”