Remember this Post?!

Well, there is a new initiative amongst the Trauma General Surgeon's called ACCESS "ACute Care Emergency Surgical Services" that will enable surgeon's to have protected OR time Monday to Friday between 1600-1900. This will include cases such as Lap Appy's and Lap Chole's. Below is the latest policy for ACCESS. It begins today in the O.R. (Today was the first day I've heard about this) Any questions please refer them to Dr. Brenneman.


ACute Care Emergency Surgery Service (ACCESS)

Background

The ACCESS service is designed to create a new medical model of care for existing Emergency Department general surgery patients. The main principle of this model is based on a one week service rotation, wherein one general surgeon is responsible for managing a team solely dedicated to the care of all new ED consults, and existing ACCESS service patients.

In the recent 5 year review of Sunnybrook’s Division of General Surgery, Dr. Don Buie commented that ….“This (ACCESS) initiative has the potential to concentrate general surgical care separating it from the two primary focuses of oncology and trauma. It allows academic surgeons to plan their time more efficiently by concentrating call at specific times. Thus blocks of time without call can be more productive. It can be integrated into a trauma model as both services can be done on a weekly rotational basis. In addition it maintains the focus of individual services within their area of expertise. From an educational point of view it provides a concentrated general surgery experience for a resident assigned to this service. During the day, the remaining residents can focus on learning objectives for their assigned rotation. As trauma surgery is becoming more non-operative, there is a need to ensure that trauma surgeons keep up their skill level. The ACCESS service provides such an outlet.” Further, Dr. Buie recommended in his report that the hospital should “ensure there is dedicated operating room time so that urgent/emergent cases can be done in a timely fashion without interrupting elective bookings. This improves efficiency of patient care both for the acute service and the emergency department.”

This model of care has been recently implemented in some large AHSCs in Canada including Calgary, Montreal, and Vancouver. It has also evolved in the United States in conjunction with existing trauma surgery services at level 1 trauma centers. The reasons for Sunnybrook to implement an ACCESS service include benefits to the patient, surgical trainee, hospital, and surgeon, as outlined below:

Potential Benefits of an Acute Care General Surgery Emergency Service Model of Care

1. Benefits for the patient
· improve patient care with shorter time to GS consultation in the ED
· improve patient care by more timely access to the OR for semi-emergent surgery (eg. appendicitis, acute cholecystitis)
· improve overall patient and family experience on general surgery service, attributed to advantages of having a dedicated service managing all general surgery emergency patients

2. Benefits for the general surgery residents, medical students
· increased focus on emergency general surgery education
· improve bedside teaching with a dedicated ACCESS team for these patients
· formal teaching rounds on general surgery (non-trauma) emergencies
· easier to deal with one attending surgeon for all emergency GS patients on a dedicated ACCESS team, than to deal with multiple attending surgeons for fewer patients on each (existing) team

3. Benefits for the hospital
· improve hospital LOS for emergency general surgery patients
· improve patient flow for general surgery patients, thereby improving bed utilization and efficiency
· improve time to consultation and time to final management decision for general surgery patients in the Emergency Department
· improve patient satisfaction scores
· decrease general surgery after hours OR utilization
· easier for the general surgery ward nurses to deal with one resident/attending surgeon team for the week than to deal with multiple residents and multiple attending surgeons for the same compliment of patients

4. Benefits for the general surgeons
· compartmentalize general surgery acute care into weekly blocks
· will decrease the number of after hours general surgery operations
· helps to protect time for research
· ensures continuity of patient care in one week blocks
· financial issues (in a fee-for-service model) unclear at this point in time, but likely to be neither a gain nor a loss of income for the general surgeon as a result of this model of care.


Description of the Acute Care Emergency Surgery Service

The new ACCESS service will involve the following:
1. The patients to be INCLUDED on this new service are Emergency Department general surgery patients, and in-patient general surgery consults (see exclusions).
2. The patients to be EXCLUDED are surgical oncology patients (eg. malignant bowel obstruction, new cancer patient referrals), trauma patients (patients with any injury, regardless of whether or not they were seen by the trauma team), consults for PEGs and trachs (to be done by trauma surgeons), and post-op elective surgery patients with complications (to be managed by the original operating surgeon).
3. One week rotation for the attending general surgeon starting every Friday at 8:00am
4. The general surgeon on ACCESS will be expected to restrict other scheduled clinical work during that week in order to provide dedicated time to the ACCESS service. For example, the ACCESS surgeon will not have an elective scheduled OR list while on the ACCESS service.
5. Friday’s 8:00am sign-over is intended to allow for seamless continuity of care of general surgery patients. This may be a challenge and will require particular attention in order to achieve good outcomes. Sign-over will include both the “incoming” and the “outgoing” ACCESS attending surgeons, ACCESS team residents and medical students, and representation from C6 nursing and social work. It will occur in a reserved room on or near C6. These rounds will be focused working rounds for sign-over purposes only, and should take up to 30 minutes.
6. The general surgeon on service for the week is MRP for these general surgery patients. If a patient is admitted during an “off surgeon” night on call, the patient is to be admitted under the “off” general surgeon and transferred to the ACCESS surgeon the following morning.
7. The general surgeon’s service will round every day (7 days) on all ACCESS service patients. Particular attention to timely hospital discharge planning will be an important aspect of these rounds.
8. A nurse practitioner, patient care coordinator, or charge nurse will attend these daily rounds (weekdays) and assist with discharge planning.
9. There will be protected “ACCESS” OR time every weekday (Monday to Friday) for 3 hours to allow for overnight appes, lap choles, etc to get to the OR in a more timely fashion, thereby decreasing their length of stay. This OR time has been approved by the OR Management Committee, and will occur between 1600 – 1900 hours on weekdays for a 3 month trial period commencing July 7, 2008. If an ACCESS patient needs to go to the OR emergently during the day, the ACCESS case will bump the general surgery scheduled operating room for that day. However, the GS scheduled OR will be allowed to run until 1900 hrs on that day (in the ACCESS OR time).
10. OR cases – the ACCESS attending surgeon must be in the OR at all times with the resident team. This must be an efficient operating room. All pre-op ACCESS patients must be ready for the OR when the OR calls for the patient. The OR booking sheet should indicate “ACCESS” surgical case.
11. ED consults to the ACCESS team. The ACCESS team will commit to a maximum 30 minute response time (measured from the time the consult is called to the time the patient is first seen by the ACCESS team), and a 2 hour time from consult to final decision regarding disposition.
12. If any ACCESS patient becomes chronic, the MRP stays with the ACCESS team. It is felt that the ACCESS team is best suited to deal with placement of these patients.
13. The residents on this new service rotate for one to two month blocks. This will create a new resident team at Sunnybrook and ideally will include a senior resident, junior residents and medical students.
14. The attending surgeon for the week will rotate as per a predetermined schedule. This schedule will be created 3 months in advance, and will include a 6 month period. (for example, create the July-Dec 2008 schedule in April 2008).
15. ACCESS patient follow-up is with the surgeon who did the operation. If no surgery, then the surgeon on service at the time of hospital discharge will arrange follow-up.
16. A one page outcome measures and quality improvement data collection sheet will be completed by the attending ACCESS surgeon daily in a prospective fashion. This data will be entered into a database by general surgery administrative staff.
17. Discharge summaries are the responsibility of the ACCESS surgeon on service at the time of hospital discharge (ie. the MRP).
18. All general surgeons at Sunnybrook will be expected to participate in the ACCESS service rotation in an equitable distribution. However, the trauma general surgeons have the option of only taking part in the “off surgeon” on call nights, because they already have a 1 in 5 trauma on call commitment, and in addition 3 of them also have ICU weeks on call.


Weekly On Call Surgeon Schedule

10-on and 4-off schedule
Surgeon A = ACCESS surgeon of the week
“off surgeon” is done by either the same surgeon or different surgeons for that particular week. “Off” call is from 7:00pm to 7:00am on weekdays and 5:00pm to 8:00am on Saturday night.