A systematic review of dedicated models of care for emergency urological patients

Epidemiology and management of urological emergencies in a tertiary care setting in Scandinavia

OBJECTIVE

To develop a baseline database detailing the distribution of urological emergencies and to define their epidemiological profile in a tertiary care setting, with the hope of providing important data for health planning.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective study was conducted on all patients presenting with urological emergencies at the Emergency Department (ED) of the NU Hospital Group in Trollhättan, Sweden throughout 2019. Medical records of identified patients were reviewed retrospectively to summarize pertinent information.

MAIN RESULTS

In 2019, 2 433 patients visited the ED with urological complaints, with 71% being male. Most patients (83%) were self-referred and 15% referred by general practitioners (GPs). Loin pain, infectious symptoms, and lower urinary tract symptoms were the most common complaints. Urinary and genital infections (UGIs) were the most frequent diagnoses (37%), followed by urolithiasis (24%). 28% of patients required admission, particularly for UGIs (42%). Self-referred patients had a higher admission rate compared to those referred by GPs. Radiological investigations were performed in 48% of cases, though 65% showed no urological pathology.

CONCLUSIONS

Most patients self-referred to the ED, and many required hospitalization, particularly for UGIs. Enhancing the management of urological emergencies in primary care and refining guidelines for acute imaging could contribute to more efficient use of healthcare resources.

[Position paper of the working group Urological Acute Medicine]

Emergency patients with acute genitourinary system diseases are frequently encountered in both outpatient and clinical emergency structures. It is estimated that one-third of all inpatients in a urology clinic initially present as an emergency. In addition to general emergency medicine knowledge, specialized urologic expertise is a prerequisite for the care of these patients, which is needed early and specifically for optimal treatment outcomes. It must be taken into account that, on the one hand, the current structures of emergency care still lead to delays in patient care despite positive developments in recent years. On the other hand, most hospital emergency facilities need urologic expertise on site. In addition, politically intended changes in our health care system, which drive an increasing ambulantization of medicine and condition a further centralization of emergency clinics, become effective. The aim of the newly established working group "Urological Acute Medicine" is to ensure and further improve the quality of care for emergency patients with acute genitourinary system diseases and, in consensus with the German Society of Interdisciplinary Emergency and Acute Medicine, to define precise task distributions and interfaces of both specialities.

The acute surgical unit: An updated systematic review and meta-analysis

OBJECTIVE

To systematically review comparative studies on the acute surgical unit (ASU) model.

METHODS

Searches were performed of Cochrane, Embase, Medline and grey literature. Eligible articles were comparative studies of the Acute Surgical Unit (ASU) model published 01/01/2000-12/03/2020. Amongst patients with any diagnosis, primary outcomes were length of stay, after-hours operating, complications and cost. Secondary outcomes were time to surgical review, time to theatre, mortality and re-admission for patients with any diagnosis, and cholecystectomy during index admission for patients with biliary disease. Additional analyses were planned for specific cohorts, such as patients with appendicitis or cholecystitis.

RESULTS

Searches returned 9,677 results from which 77 eligible publications were identified, representing 150,981 unique patients. Cohorts were adequately homogenous for meta-analysis of all outcomes except cost. For patients with any diagnosis, compared with the Traditional model, the introduction of an ASU model was associated with reduced length of stay (mean difference [MD] 0.68 days; 95% confidence interval [CI] 0.38-0.98), after-hours operating rates (odds ratio [OR] 0.56; 95% CI 0.46-0.69) and complications (OR 0.48, 95% CI 0.33-0.70). Regarding cost, two studies reported savings following ASU introduction, while one found no difference. Amongst secondary outcomes, for patients with any diagnosis, ASU commencement was associated with reduced time to surgical review, time to theatre and mortality. Re-admissions were unchanged. For patients with biliary disease, ASU establishment was associated with superior rates of index cholecystectomy.

CONCLUSION

Compared to the Traditional structure, the ASU model is superior for most metrics. ASU introduction should be promoted in policy for widespread benefit.