Model of Care
TACS Model of Care
Liverpool Hospital is one of the largest hospitals in Australia and is currently the only verified Level 1 Trauma Centre in Sydney. It has also the busiest emergency department, seeing the highest number of emergency surgical presentations annually. We have annually just over 4000 acute surgical admissions through the Emergency Department (ED), of which nearly 1100 are trauma admissions.
These numbers are predicted by the Ministry of Health to increase by 40-50% by 2026 for the following reasons: the known increasing population and aging population, plans to build a second major airport and consequent increased roads, freeways and major housing developments. We are also a designated hospital for disaster by virtue of our Level 1 standing.
In order to accommodate this significant increase in workload, our Emergency Department is undergoing a major redevelopment which will include Specialty Acute Assessment Units including Emergency Surgery and Trauma. It is with this in mind that we originally proposed this model of care and have now set up this well-functioning Unit.
Patients requiring acute surgical care constitute a major component of the workload (50-60% of operative load) of our entire surgical department. These patients are frequently the sickest, are often elderly with considerable co-morbidities and poorer outcomes and are often complex and resource intensive. In the last decade, many professional publications have suggested that the standard of care of surgical emergencies needs significant improvement and has been called the “neglected disease of modern society”.
The Trauma and Acute Care Surgery Unit (TACS) Philosophy
Multiple models of acute care surgery have been developed over the last couple of decades. In overseas Level 1 Trauma Centres, emergency surgery care has been incorporated into trauma units to create a model of acute care surgery that uses the well-established structure of trauma services to provide care for emergency general surgery patients. Across North America and Europe the concept of separate dedicated TACS units is growing and increasingly being seen as the preferred model of care.
This provides acutely ill surgical patients with surgeons who are specifically trained to care for them, increases the caseload of trauma surgeons, and better uses the multidisciplinary resources available at trauma centres. The literature clearly demonstrates that dedicated Trauma and Acute Care Surgical Units reduce emergency department response times, times to diagnosis and definitive care, as well as reducing lengths of stay (LOS), complications and consequently costs. Acute care surgery provides many opportunities to improve access to care, augment the standards of emergency surgical care delivery and improve outcomes for patients.
The “golden hour” concept of trauma care has led to the development of trauma teams and trauma systems with consequent high-quality care given to severely injured patients, with measurable improved outcomes and performance. It has been clearly shown in the trauma literature that consultant surgeon led trauma resuscitations and management result in significantly better patient outcomes. A trauma model of care should be applied when managing acute general surgery patients with dedicated teams, protocols and clinical areas, all working to optimise timely definitive care.
Patients with diagnoses of appendicitis, intestinal obstruction, gallstone complications, diverticulitis, gastrointestinal haemorrhage, intra-abdominal sepsis, perforated viscus, severe surgical infections and mesenteric ischemia can be assessed more rapidly by dedicated ACS consultant led teams. A Consultant led service, working with a dedicated multidisciplinary team, will lead to more accurate and timely decision making, a reduction in unnecessary clinical investigations, greater trainee supervision and sharing of expertise and more cost-effective management and financial savings within the health service as well as increased staff satisfaction. Patients requiring subspecialty advice and/or management would be discussed with and possibly transferred to the relevant teams if deemed appropriate (e.g. complicated colorectal problems or complex Upper GIT issues).
Further to patient outcomes, an Acute Care Surgery Unit is also critical for the education and training of our future emergency care surgeons. In North America there is a dedicated Fellowship as well as clear educational goals and objectives for trainees (non-operative and operative). Liverpool, in affiliation with the University and College of Surgeons, is seen as the national leader with our 2 year post-graduate Acute Care Surgery Fellowship and also which is being looked at by the Australasian Royal College of Surgeons (RACS) and the General Surgeons of Australia (GSA) for accreditation as a complete post-fellowship training pathway.
It is in this light that we have set up the Acute Care Surgery Unit – which is effectively the merger of Trauma and ASU (Acute Surgical Unit) into one large unit. This is the only one of its kind in Australia. This Unit admits and manages all trauma and emergency general surgery patients from 6am until 4pm last consult. The next day we take over most trauma patients and any emergency general surgery patients requiring surgery who have not been operated on overnight or need another opinion.
The Current Model
A great number of changes have occurred since the formation of the Unit back in June 2019. We have an excellent model of care which has been very well received by all Hospital Departments and the Executive. It is an entirely Consultant led (Full-time Staff Specialists) Unit and ensures timely specialised care.
We are verified as a Level 1 Trauma Centre – the only one current in Sydney – and we have also had the trauma component of the TACS Fellowship approved by the Royal Australasian College of Surgeons with 5 years accreditation (Post Fellowship Education and Training Program).
The current Department has the following staffing:
- 5 TACS Consultants
- 2 TACS Fellows
- 4 Registrars – 2 SET and two non-SET
- 4 Junior Medical Officers
- 5 Nursing Staff – District CNC 2, Liverpool CNC 3 & CNC 1 + 2 afterhours Case Manager CNS 2
- 2 Administrative Staff
- 1 Education and Training Manager
- 1 Trauma Data Manager
The current model now has the following resources:
- Elective Lists – 4 per month full day
- 3 Outpatient Clinics weekly – Trauma, ASU and General Surgery
- ASU afternoon dedicated operating lists – 5 per week emergency lists
Acute Care Surgery Fellowship
What is currently lacking in Australia is a structured training programme in trauma, emergency general surgery and intensive care among current general and subspecialty surgeons. Emergency work is a critical part of all public and some private hospital work but many surgeons do not want to take part or feel uncomfortable in doing so.
Liverpool Hospital is seen as the national leader with our two year Trauma and Acute Care Surgery Fellowship. This has opened up the way for a new career pathway not only for major teaching hospitals or level one trauma centres but for the regional or rural surgeons who will deal with these patients and want structured, recognised training and experience in this field.
The Fellowship allows for rotations (2 monthly) between Trauma, Emergency Surgery and some Intensive Care experience as well. There are also opportunities to join subspecialties such as Neuro/Cardiothoracic/Ortho/Vascular to learn other specialty emergency work. They are also encouraged to join with teams such as upper GIT, colorectal and head and neck when their patients have been transferred for further subspecialty care. Fellows also learn the importance of non-operative care of the trauma or critically ill surgical emergency patient and complex decision making related to this.
We have been successful in having our Trauma part of this Fellowship accredited by RACS and are currently involved in discussions and meetings with the GSA and RACS in order to accredit the ASU component of this Fellowship. There are also be opportunities to pursue training overseas with our contacts in Europe, North America and the UK.
This Trauma and Acute Care Surgery practice model provides an expanded diversified challenging operative caseload as well as providing an opportunity for team based work and consultant led care and a reasonable degree of flexibility for the surgeons.
Benefits of this Model
TACS Surgeons: Surgeons in this Unit rotate weekly in a 4 week cycle – Trauma ; Emergency Surgery (ASU) ; Second –On Surgeon responsible for all elective lists and clinics and when extra back up is required; Non-Clinical when research, administrative and education priorities are the focus. This Trauma and Acute Care Surgery practice model provides an expanded diversified challenging operative caseload as well as providing an opportunity for team based work and consultant led care and a reasonable degree of flexibility for the surgeons.
Patients: As previously discussed and shown, this model mostly benefits the patient. Each patient is seen and reviewed by a Consultant on a daily basis. It results in better outcomes, fewer complications, shorter LOS and more satisfied patients.
Hospital: The model will, as shown already, translate to significant cost savings from decreased LOS, reduced complications and reduced time to decision making and definitive care. Elective operating will no longer be impacted with a dedicated and separate emergency model. It also has saved VMO costs given our Unit is on call each week day where previously this was covered by on call VMOs (see below).
Surgical Department: VMO Consultants benefit by no longer having their on call commitments disrupting elective operating, consulting rooms and other competing professional commitments.
Emergency Department: Consultant led care positively impacts the management of patients with more rapid assessments, consultations and reviews and decisions regarding disposition and definitive care. The ACS Unit could run the surgical admitting/assessment area of the Emergency Department.
Intensive Care Unit: The Unit benefits from daily consultant led rounds, decision making as well as necessary surgical interventions done in a timely manner.
Other hospital ward/clinical areas: All wards function more efficiently with faster and clinically sound decisions for management, discharge and turnover.
JMOs/SRMOs/REGs: Consultant led education and training. Excellent case load and operating opportunities.
Fellows: As previously discussed, a great opportunity to be trained in trauma and emergency surgical care for those wishing to pursue a career in TACS or seeking a hospital appointment in more rural or remote locations.
Nursing Staff: There is improved communication with a dedicated consultant led team managing all acute admissions and operating lists. Staff will benefit from regular in-services as well as having direct involvement in multidisciplinary rounds.