Emergency room surgical workload in an inner city UK teaching hospital

Table 1 details the distribution of patients according to specialty, diagnosis, number of admissions as well as sex ratios, and length of stay. Abscesses (11%), non-specific abdominal pain (9.7%) and acute appendicitis (6.6%) were the commonest general surgical diagnoses. Among trauma patients neurological injury (9.6%) was the commonest reason for admission. As expected intuitively, male to female ratio was different according to specialties: vascular (2.8:1), trauma (4.4:1), general surgery (1.1:1). The younger patients (<40 years) had a significant male preponderance (1.8:1) and the sex ratio became 1 only in over 80 year age group. Of all emergency surgical admissions, 605 (43.5%) required operative intervention. More than half (346 (57%)) of general surgical emergency admissions required operative intervention while only 32% (195) of trauma and 11% (64) of vascular emergencies required operative intervention. Types of operations, demographics, length of stay are detailed in table 2.

The median length of stay was 4 (2–8) days. Vascular patients stayed in hospital significantly longer than trauma or general surgery patients (Kruskall Wallis, df = 2; Chi-square statistic = 106.8, P < 0.001; Figure 5), possibly because most vascular patients were elderly. Elderly patients (> 80 years) stayed 6 days longer in the hospital as compared to those below the age of 40 years (Kruskall Wallis, df = 3; Chi-square statistic = 129.7, P < 0.001; Figure 6). Patients who underwent surgery stayed a median of 4 days as compared to those without surgical intervention (3 days). It is worthwhile noting that laparoscopic appendicectomy patients stayed a median of 3 days as compared to 2 days for open appendicectomy. All abscesses stayed a median of 2 days in hospital.

The strength of this contemporaneous data from one surgical department in the UK is prospective collection with complete follow-up, along with time of intervention. This allows us to get some estimates on the dynamic nature of emergency surgery, an aspect which is generally underestimated. Inevitably, a single centre data has limitations as to the generalizations which can be derived from them. In addition, there are other aspects of this work, which should be borne in mind. The Royal London Hospital serves a young, multiethnic, socio-economically deprived and diverse, largely immigrant population of the Tower Hamlets borough of London. This population has higher rates of accidental injuries than the rest of England. [5] It is, also, the site of the only Helicopter emergency medical service (HEMS) in London. [7, 8] As a result, there is a higher intake of trauma patients, compared to the rest of the UK, who tend to be younger. This would explain lower median age of 41 (28–60) years as compared to other UK studies [46.9 (range 12–99) years in 1984 and 52.6 years in 1998. [4, 9‐12] Though only 6% of patients were brought in by the HEMS, they considerably impacted on the workload [8, 9] as they were usually poly-trauma patients requiring muti-specialty care and investigational facilities as well as theatre space. Moreover, they also tended to stay in hospital longer despite a younger median age (Table 1).

The incidence of common general surgical diagnoses such as abscess, and non-specific abdominal pain, was similar to those reported by Stower et al [12] and Irvin [11]. The much higher proportion of trauma admissions (28%) compared to the 5.3% reported by Stower et al [12] and to the 2% reported by Bain et al [9], is in keeping with the prominent role of a designated major trauma center for London. Only 11% of patients were referred by General Practitioner (GP) and there were a high proportion of self-referral patients, and those brought in by ambulances (surface and air). Dookeran et al suggested that up to 41% of such admissions referred by General Practitioner were inappropriate [13] which could not be confirmed in our study.

Monday was peak day of admission with Saturdays experiencing a dip which is different from results of Stower et al who demonstrated that there was no change of admission rate over the week. [12] Possible explanation could be proximity to a large work-force of over a million extra individuals over the working week in the City of London, a major financial services hub. Additionally, as can be expected the peak time for admissions during the day was from mid-day to mid-night, and this fact, makes a case for appropriate resource allocation.

The overall median length of stay of surgical emergency patients was 4 (IQR 2–8) days. This was significantly shorter than the mean length of stay for both elective and emergency cases in all specialties in the UK (7.1 days) as reported by HES (Hospital Episodes Statistics) online in 2003–2004 and reflects the dynamic nature of emergency surgical admissions. [14] Older patients and vascular emergencies (also an older cohort) tended to stay longer possibly due to co-morbidities. [4, 10, 15, 16] The discharge delays were often due lack of provision of social services and rehabilitation after discharge. [14, 16, 17] Polytrauma patients also tended to stay longer. It is interesting that despite RCTs showing a shortened stay for laparoscopic procedures over open procedures, this is not always borne out in day-to-day clinical practice, for procedures such as appendicectomy (median stay of 3 days for laparoscopic versus 2 days for open procedure). [18]

The emergency operation rate (43.5%) was much higher compared to around 30.3% in other series. [9] This could be due to the high number of trauma patients and tertiary referral status or perhaps just a higher threshold for admitting patients, due to availability of investigations in ER. Incision and drainage of abscess (I&D), the commonest operation was performed in 22.5% of all operative cases. This again differs from all previous studies in which the commonest emergency procedure was appendicectomy (15% appendicectomy Dawson study, 11% in Stower study). [2‐4, 10, 15] However the abscesses stayed for a median of two days (two overnight stays, the first of them being for waiting for a theatre slot). This may reflect the lower prioritization for emergency theatre space, given other demands in a major trauma center, where only one theatre is fully staffed for emergency general surgical operations. Better theatre and admission planning would be required. A current pilot scheme looks at discharge from A&E followed by same/next day admission for urgent surgery (such as I&D) on a planned emergency list. It is interesting to note that though the admission sex ratio (M:F) was 1.7:1, the ratio for operation was 3.1:1 (tables 1 and 2). This is due to male predominance for trauma patients (requiring a higher rate of operative interventions) and female predominance for non-specific abdominal pain, gall bladder and diverticular disease as well as gynaecological conditions; all of which had lower intervention rate. Thus, only operations such as diagnostic laparoscopies, other laparotomies (often diagnostic and for diverticular disease) and emergency laparoscopic cholecystectomy were more common for women.

A major trauma centre and tertiary teaching hospital offers an array of training opportunities for the trainee surgeon through exposure to a wide-range of poly-trauma and emergency surgical patients requiring urgent surgical decisions and frequent operative intervention and a rapid turnover. [19] With the introduction of European Working Time Directive (EWTD, an Europe-wide legislation leading to reduction of average working hours from 72 hours to 48 hours) [20] and consequent reduction in the exposure to elective surgery, the findings of this study suggest that trainees gain valuable experience from exposure to a broad spectrum of emergency surgery in a major trauma centre. This fact should be reflected in their training curriculum and log-book. Data such as these should also be considered for workforce planning during re-organisation and rationalisation of health services similar to those planned for London [6]