Department of Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
Department of Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
BMJ Open Qual. 2021 Nov;10(4). doi: 10.1136/bmjoq-2021-001567.
A well-designed ambulatory emergency care (AEC) can alleviate demand for inpatient beds by reducing admissions or supporting early discharges. Increasing service demands and workforce gaps present major challenges to surgical departments. Physician's associates (PAs) have been suggested as one way to address this, but previous barriers include lack of job role clarity, and inability to prescribe or request ionising radiation. An AEC clinic using PAs supported by senior decision-makers could improve patient care and provide workforce stability alongside a new capacity for successful PA positions.
An emergency surgery AEC pathway was introduced to a single centre in anticipation of a second COVID-19 wave. All emergency surgical referrals were prospectively collected over 3 months (November 2020 to February 2021) with minimum 30-day follow-up. The primary aims were to evaluate clinical outcomes and success of a new AEC PA role.
A total of 175 patients were entered into the study. The median time from request for senior review to treatment decision was 26 min (IQR 9-62 min). The primary discharge rate was 38.3% (n=67), while the overall discharge rate without needing admission was 84% (n=147). Of the total 28 (16.0%) patients requiring admission, 18 (10.3%) were clinically appropriate. Four patients represented with Clavien-Dindo Grade II complications and above: two grade II (1.1%) and two grade IIIb respectively (1.1%). The role of the PA was well defined with no team discord. No patient complaints were received.
During the COVID-19 pandemic, an emergency surgery AEC pathway was implemented by combining a PA with a senior decision-maker, enabling fewer emergency admissions and significantly reduced time-to-reach-treatment decisions. This in turn facilitates bed-flow and minimises delays in patient treatment. The use of a well-defined PA role in this setting shows initial success and should be considered as a long-term role.
精心设计的门诊急救护理（AEC）可以通过减少入院或支持提前出院来减轻对住院床位的需求。服务需求的增加和劳动力缺口给外科部门带来了重大挑战。医师助理（PA）被认为是解决这一问题的一种方法，但以前的障碍包括工作角色不明确，以及无法开处方或要求进行电离辐射。在有高级决策者支持的情况下，建立一个使用 PA 的 AEC 诊所，可以改善患者的护理，并提供劳动力的稳定性，同时为成功的 PA 职位提供新的能力。
在预期第二波 COVID-19 浪潮的情况下，在一个单一的中心引入了一个急诊手术 AEC 途径。在 3 个月（2020 年 11 月至 2021 年 2 月）内，前瞻性地收集了所有的急诊手术转诊，并进行了至少 30 天的随访。主要目的是评估新的 AEC PA 角色的临床结果和成功情况。
共有 175 名患者进入研究。从请求上级审查到治疗决策的中位数时间为 26 分钟（IQR 9-62 分钟）。主要出院率为 38.3%（n=67），而无需入院的总出院率为 84%（n=147）。在总共需要入院的 28 名患者中（16.0%），18 名（10.3%）是临床合适的。有 4 名患者出现了 Clavien-Dindo 分级 II 级及以上的并发症：2 级（1.1%）和 3b 级（1.1%）各 2 例。PA 的角色定义明确，团队之间没有分歧。没有收到患者的投诉。
在 COVID-19 大流行期间，通过将 PA 与高级决策者相结合，实施了一个急诊手术 AEC 途径，减少了急诊入院人数，并显著缩短了达到治疗决策的时间。这反过来又促进了床位的流动，最大限度地减少了患者治疗的延迟。在这种情况下，使用明确界定的 PA 角色显示出初步的成功，应被视为一个长期的角色。
