Guideline

NSW Emergency Surgery Guidelines and Principles for Improvement

Summary The Guidelines support hospitals, Local Health Districts and Specialty Health
Networks to plan their emergency surgery services based on a predictable long-term
workload
Document type Guideline
Document number GL2021_007
Publication date 18 May 2021
Author branch Agency for Clinical Innovation
Branch contact (02) 9464 4711
Replaces GL2009_009
Review date 18 May 2026
Policy manual Patient Matters Manual for Public Health Organisations
File number H20/100010
Status Active
Functional group Clinical/Patient Services - Critical Care, Governance and Service Delivery, Surgical
Applies to Ministry of Health, Local Health Districts, Specialty Network Governed Statutory
Health Corporations, NSW Ambulance Service, Public Hospitals
Distributed to Ministry of Health, Public Health System, NSW Ambulance Service
Audience Local Health Districts & Network Executives;Managers and Clinicians

Secretary, NSW Health

 NSW EMERGENCY SURGERY GUIDELINES AND PRINCIPLES FOR
IMPROVEMENT

GUIDELINE SUMMARY
Emergency surgery is an important and significant component of surgical service
provision, accounting for up to 45% of surgery delivered in public hospitals each year.
NSW hospitals have a long history of delivering high-quality surgical services, and
timely access to emergency care is key to supporting optimal outcomes for patients and
communities.
This iteration of the NSW Emergency Surgery Guidelines support hospitals, local health
districts (Districts) and specialty health networks (SHNs) to plan their emergency
surgery services based on a predictable long-term workload. It aims to ensure capacity
is sufficient to meet demand, minimise unwarranted variation in care, and facilitate
monitoring for improvement to ultimately provide a supportive work environment for staff
and a safe, caring service for patients.
A revised framework for prioritisation of clinical urgency, incorporating obstetric
emergencies for the first time, is presented to support clinical decision-making.

Category Priority Maximum timeframe

A Life threatening (including 1 hour
obstetric)
B Highly critical (including 2 hours
organ/limb threatening)
C Critical 4 hours
D Urgent 8 hours
E Semi-urgent 24 hours
F Non-urgent 72 hours

KEY PRINCIPLES
The key principles supporting a safe, responsive and high-quality emergency surgical
service are further articulated.
1. Hospitals are designated for either elective or emergency surgery, or for specific
components of each.
2. Emergency surgical workloads are measured and reviewed regularly to maximise
predictability.
3. Emergency surgery capacity is matched to service demand, with consideration of
caseload, case mix and balance with elective surgery demand.
4. Where clinically appropriate, emergency surgery is scheduled in standard hours.
5. Emergency surgery cases are scheduled based on clinical need, in line with a
statewide urgency prioritisation framework and these guidelines.
6. Emergency surgery models of care are consultant-led.

GL2021_007 Issue date: May-2021 Page 1 of 2

NSW HEALTH GUIDELINE SUMMARY
 7. Evidence-based protocols are used for the assessment and treatment of
common acute surgical presentations.
8. Local escalation plans are established and agreed to facilitate delivery of best
practice patient care, communication and conflict resolution.
9. A standardised set of indicators is applied to emergency surgery to facilitate
service monitoring and continuous quality improvement.

USE OF THE GUIDELINE

The NSW emergency surgery guidelines and principles for improvement are a resource
to support this planning across all specialties, allowing appropriate allocation of the
necessary operating theatre time and resources to meet the expected demand. For
emergency surgery,
planning should also include immediate access to operating theatres for the most urgent
emergency surgery patients; sufficient staffing and equipment for safe patient care;
access to data and information to support planning; and effective leadership to foster
high-performing surgical services. Future proofing and planning are required to plan for
the predictable annual increase in emergency surgery workload.
These guidelines outline the key principles. The examples provided are drawn from
surgical specialties where emergency caseloads are generally high (orthopaedics,
general surgery, obstetrics and gynaecology and plastic surgery).
However, the principles are equally applicable to those specialties where emergency
caseloads are less (neurosurgery, vascular surgery, oral and maxillofacial surgery) or
where caseloads are relatively low (urology, cardiothoracic, ophthalmology and
otolaryngology).
The guidelines detail each of these principles more fully, guiding hospitals to better align
their services with the principles in order to deliver better, safer emergency surgical care
to their communities.

REVISION HISTORY
Version Approved by Amendment notes
May-2021 Deputy Secretary, Revised prioritisation framework, suggested clinical
(GL2021_007) Patient Experience indications, KPIs, planning resources
and System
Performance
June 2009 Director - General New guidelines
(GL2009_009)

ATTACHMENTS
1. NSW emergency surgery guidelines and principles for improvement

GL2021_007 Issue date: May-2021 Page 2 of 2

NSW HEALTH GUIDELINE SUMMARY
 aci.health.nsw.gov.au

NSW emergency surgery

guidelines and principles
for improvement
FEBRUARY 2021

Surgical Services Taskforce

 The information is not a substitute for healthcare providers’ professional judgement.

Agency for Clinical Innovation

1 Reserve Road St Leonards NSW 2065
Locked Bag 2030, St Leonards NSW 1590
T +61 2 9464 4666 | F +61 2 9464 4728
E aci‑[email protected] | www.aci.health.nsw.gov.au

Produced by: Surgical Services Taskforce

Further copies of this publication can be obtained from the Agency for Clinical Innovation website
at www.aci.health.nsw.gov.au

Disclaimer: Content within this publication was accurate at the time of publication.
This work is copyright. It may be reproduced in whole or part for study or training purposes subject
to the inclusion of an acknowledgment of the source. It may not be reproduced for commercial
usage or sale. Reproduction for purposes other than those indicated above, requires written
permission from the Agency for Clinical Innovation.

Preferred citation: NSW Agency for Clinical Innovation. NSW emergency surgery guidelines and
principles for improvement. Sydney: ACI; 2020.

SHPN (ACI) 200329-1

ISBN 978-1-76081-433-5

Version: V1. ACI_0456 [07/20] Date amended: February 2021

Trim: ACI/D20/1894

© State of New South Wales (NSW Agency for Clinical Innovation) 2021.
Creative Commons Attribution No derivatives 4.0 licence.

ACI logo is excluded from the creative commons licence.

NSW emergency surgery guidelines and principles for improvement February 2021

Contents

Summary 1

Introduction 2

Key principles of emergency surgery 3

Operational model 12

Surgical procedures requiring urgent management 13

 pplication of the urgency prioritisation framework to common

A
emergency general surgical presentations 16

Redesigning clinical services 18

Models of emergency surgery care 20

Operating theatre session planning 22

References 24

Additional evidence 26

Glossary 27

Acknowledgements 28

Agency for Clinical Innovation  www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Summary

Emergency surgery is an important and significant A revised framework for prioritisation of clinical urgency,
component of surgical service provision, accounting incorporating obstetric emergencies for the first time, is
for up to 45% of surgery delivered in public hospitals presented to support clinical decision-making.
each year. NSW hospitals have a long history of
delivering high-quality surgical services, and timely The key principles supporting a safe, responsive and
access to emergency care is key to supporting high-quality emergency surgical service are further
optimal outcomes for patients and communities. articulated.

This iteration of the NSW Emergency Surgery Guidelines 1. Hospitals are designated for either elective or
builds on the previous version, published in 2009, to emergency surgery, or for specific components
support hospitals, local health districts (LHDs) and of each.
specialty health networks (SHNs) to plan their emergency 2. Emergency surgical workloads are measured and
surgery services based on a predictable long-term reviewed regularly to maximise predictability.
workload. It aims to ensure capacity is sufficient to meet
3. Emergency surgery capacity is matched to
demand, minimise unwarranted variation in care, and
service demand, with consideration of caseload,
facilitate monitoring for improvement to ultimately
case mix and balance with elective surgery
provide a supportive work environment for staff and a
demand.
safe, caring service for patients.
4. Where clinically appropriate, emergency surgery
To develop this document, a team of subject matter
is scheduled in standard hours.
experts from across NSW was convened, including
surgeons, nurse managers, quality improvement 5. Emergency surgery cases are scheduled based
specialists and administrators, to incorporate on clinical need, in line with a statewide urgency
contemporary practices in surgical service prioritisation framework and these guidelines.
management and continuous quality improvement 6. Emergency surgery models of care are
for health systems. consultant-led.
7. Evidence-based protocols are used for the
Maximum
Category Priority assessment and treatment of common acute
timeframe
surgical presentations.
Life threatening
A 1 hour 8. Local escalation plans are established and agreed
(including obstetric)
to facilitate delivery of best practice patient care,
Highly Critical (including organ/
B
limb threatening)
2 hours communication and conflict resolution.
9. A standardised set of indicators is applied to
C Critical 4 hours
emergency surgery to facilitate service
monitoring and continuous quality improvement.
D Urgent 8 hours
The following Guideline, and associated Appendices,
E Semi-urgent 24 hours detail each of these principles more fully, guiding
hospitals to better align their services with the
F Non-urgent 72 hours principles in order to deliver better, safer emergency
surgical care to their communities.

Agency for Clinical Innovation 1 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Introduction

Emergency surgical workloads in NSW public

hospitals are predictable on an annual basis, with The key principles underpinning design
consideration of seasonal variation allowing hospitals and delivery of emergency surgery
to plan services to meet anticipated demands.
1. Hospitals are designated for either
The NSW Emergency Surgery Guidelines are a elective or emergency surgery, or for
resource to support this planning across all specific components of each.
specialties, allowing appropriate allocation of the
2. E
 mergency surgical workloads are
necessary operating theatre time and resources to
measured and reviewed regularly to
meet the expected demand. For emergency surgery,
maximise predictability.
planning should also include immediate access to
operating theatres for the most urgent emergency 3. Emergency surgery capacity is matched
surgery patients; sufficient staffing and equipment to service demand, with consideration
for safe patient care; access to data and information of caseload, case mix and balance with
to support planning; and effective leadership to foster elective surgery demand.
high-performing surgical services. Future proofing
and planning are required to plan for the predictable 4. Where clinically appropriate, emergency
annual increase in emergency surgery workload. surgery is scheduled in standard hours.

These Guidelines outline the key principles. The 5. Emergency surgery cases are scheduled
examples provided are drawn from surgical based on clinical need, in line with
specialties where emergency caseloads are a statewide urgency prioritisation
generally high (orthopaedics, general surgery, framework and these guidelines.
obstetrics and gynaecology and plastic surgery). 6. Emergency surgery models of care are
However, the principles are equally applicable to consultant-led.
those specialties where emergency caseloads are 7. Evidence-based protocols are used for the
less (neurosurgery, vascular surgery, oral and assessment and treatment of common
maxillofacial surgery) or where caseloads are acute surgical presentations.
relatively low (urology, cardiothoracic,
ophthalmology and otolaryngology). 8. L
 ocal escalation plans are established
and agreed to facilitate delivery of best
practice patient care, communication and
conflict resolution.

9. A standardised set of indicators is applied

to emergency surgery to facilitate service
monitoring and continuous quality
improvement.

Agency for Clinical Innovation 2 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Key principles
of emergency surgery

Agency for Clinical Innovation 3 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

1. 
Hospitals are designated for either 2. Emergency surgical workloads are
elective or emergency surgery, or measured and reviewed regularly
for specific components of each to maximise predictability
Not all hospitals have the full complement of available Although emergency surgery is generally
services to meet the needs of every patient predictable in volume, it is to be expected that spikes
presenting for emergency surgery. While patients in activity will often occur.
should receive care as close to their home as possible,
The assessment of emergency surgery workload
transport or travel will sometimes be required to
should be reviewed every 12 months at a minimum,
access specialist emergency surgical care.
and capacity for emergency surgery altered
Emergency surgery sessions are as important as elective accordingly. This should also include consideration of
surgery sessions, with evidence suggesting separation seasonal variation in workload and planning for
of these into two discrete streams allows more efficient holiday periods. Although these are often referred to
use of resources, a more effective workforce, and leads as ‘low activity periods’, some hospitals report up to
to better care and outcomes for patients.1 33% increase in demand for theatre access due to
population changes over the holiday period and
A lack of separation of these work streams, with
fewer available elective theatre sessions.
shared processes, structures and teams for both
elective and emergency surgery, can lead to Many hospitals experience a consistent annual
imbalances in resource allocation and competing increase in emergency surgery workload. This
priorities. As a result, planning for an emergency expected annual increase must be acknowledged by
surgical service is more complex and there is an clinicians and managers and factored into the
impact on staff workload and wellbeing. It may also review process. The increased resources to manage
be necessary to perform more emergency cases the expected workload should be provided.
after hours, which can have significant implications
A number of data sources exist to facilitate
on resource and patient outcomes for hospitals.
assessment of surgical load at the LHD and facility
Separation of emergency surgery from elective level. These include:
surgery between hospitals and local health districts
• local health information and performance units
(LHDs) will require cross-appointment of surgeons to
fulfil their elective and emergency contributions. • the Activity Based Management Portal, including
the Clinical Variation App
The separation of elective and emergency surgical
• Enterprise Data Warehouse for Analysis,
services has been successfully implemented in most
Reporting and Decision Support (EDWARD) and
NSW hospitals, such as orthopaedic, obstetric,
reporting application OPERA.2,3
trauma and hand surgery. Further application of this
principle, alongside regular review and monitoring of These data sources should be reviewed in the
resources, workload and outcomes, will support context of the corresponding elective surgical load,
effective load-balancing across elective and emergency department activity and availability of
emergency surgical streams in the longer term. associated hospital resources such as intensive care
and close observation beds, medical imaging,
pathology and allied health services.

Agency for Clinical Innovation 4 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

3. Emergency surgery capacity is • emergency surgery caseloads are so low in a

metropolitan hospital that there is no predictability,
matched to service demand, with
it may be appropriate to consider whether an
consideration of caseload, case emergency surgery service is justifiable, and assess
mix and balance with elective the potential impact of service consolidation. A
surgery demand district-wide approach to emergency surgery
services should be considered to ensure appropriate
Measuring and reviewing emergency surgery access to care for local communities
workloads allows hospitals and networks to be better
• emergency surgery caseloads are high, occasional
informed about their historical demands. It also
irregular peaks of activity can occur. An escalation
facilitates better planning and allocation of resources
plan should be developed, endorsed by the
to meet anticipated future caseload and mix. LHDs
hospital executive, and communicated to all
and specialty health networks (SHNs) may wish to
stakeholders so that these irregular peaks are
consider reviewing and planning specialty demand at
managed in a coordinated manner.
the district or network level to design a more cohesive
surgical service for their local communities. Hospital, regional and state disaster recovery plans
already exist to deal with unpredictable and
Operating theatre resources should be allocated based
potentially overwhelming activity spikes. Escalation
on expected emergency surgical workload, including
plans for irregular peaks of emergency surgery
appropriate anaesthetic, surgical and intensive care
activity should be aligned with these plans.
resources for high-risk cases. The service model most
suitable for emergency surgery will vary according to a As there is a limited number of operating theatre
number of factors. In hospitals where: sessions for caesarean sections, patients are often
scheduled for elective caesarean section close to their
• emergency surgery caseloads are high, the minor
due date. As a result, many patients go into labour
variation in volume should be accommodated
prior to their planned caesarean section, and thus
through theatre session planning
proceed directly to an emergency caesarean, creating
• emergency surgery caseloads are high in a vacancies in elective obstetric surgery sessions. This
particular specialty, a specific emergency surgery creates opportunity to review theatre utilisation and
model for that specialty should be considered (for reorganise elective surgery lists where the efficiency
example, dedicated emergency orthopaedic or of theatre and procedure suite time may be improved.
obstetric theatre sessions). Dedicated emergency
theatres should be considered when: Hospitals should also consider incorporating a
dedicated operating theatre when building or
− 30% or more emergency cases wait longer than
redesigning delivery suites. This would enable
the recommended time for surgery
emergency caesarean sections to be undertaken
− 30% or more emergency theatres run over time independently of other theatre suites and allow the
(after 10pm) obstetric team to mitigate the impact of emergency
− two or more emergency lists are required per day caesarean sections on other surgical specialties.
to meet demand4 Where this is not possible, the number and allocation
of emergency theatres should include a recognition
• caseloads are low across a number of specialties, of the needs of emergency caesarean sections.
the combined specialty caseload may facilitate
adoption of an emergency surgery model to meet
these combined needs

Agency for Clinical Innovation 5 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

4. Where clinically appropriate, • increases consultant-led emergency surgery

management
emergency surgery is scheduled
in standard hours • increases registrar or junior staff supervision
• increases access to fully staffed radiology,
A key determinant in emergency surgery is to identify pathology and allied health services
the surgery that should be performed urgently, that • reduces number of call backs and after-hours
is, life- and limb-threatening conditions. Adequate operating for surgeons, anaesthetists and their
theatre access must always be available to enable teams
this small proportion of emergency surgical work to
• reduces elective case cancellations and elective
be performed without delay or compromise.
list interruption, as dedicated emergency time
The time of day, or day of the week, should present within the theatre suite is available
no limitation to care provision in hospitals designated • improves outcomes for patients
to provide 24-hour access to emergency surgery. All • increases predictability for staff rostering and budgets.
other surgery, elective and emergency, where it is
clinically appropriate, should be scheduled to occur in The decision to operate outside of standard hours
standard hours, generally between 8am and 5pm, should be underpinned by a comprehensive risk
across a seven-day work week. assessment to determine if the patient will be
clinically compromised if they do not receive an
Scheduling emergency surgery in standard hours: urgent operation. It should not be determined by
• enhances predictability for patients and families perceived or actual limitations of standard-hours
with respect to scheduled operating theatre time access to operating theatre sessions.

• improves predictability for surgeons and The availability of surgeons to undertake the
surgical teams standard-hours emergency surgery will generally
require adjustments to their rostering arrangements

Table 1. Prioritisation framework for urgency of emergency surgery

Category Priority Definition Maximum

timeframe
A Life threatening Mother or fetus in immediate risk of loss of life 1 hour
(including obstetric)
B Highly Critical (including Life threatening cases requiring urgent access to the next 2 hours
organ / limb threatening) available theatre
C Critical Requires the next available theatre 4 hours
Patient or fetus is physiologically stable, but at significant risk of
deterioration, systemic decompensation or risk to organ survival
D Urgent Patient is physiologically stable, but at risk of deterioration 8 hours

E Semi-urgent Patient is stable, with low or negligible risk of deterioration 24 hours

F Non-urgent Patient is stable, but not suitable for discharge 72 hours

Agency for Clinical Innovation 6 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

for emergency surgery and their allocated elective 5. Emergency surgery cases are
surgery sessions. Similarly, realignment of elective
scheduled based on clinical need,
and emergency surgery sessions may necessitate
in line with a statewide urgency
reorganisation of standard-hours sessions to
accommodate emergency surgery appropriately. prioritisation framework and
these guidelines
In some hospitals and specialties, standard hours
may be extended on some days of the week to Emergency surgery cases should be scheduled
incorporate a ‘twilight’ theatre session (up to 10pm), based on clinical priority. These patients are often
or include routine weekend daytime and evening critically unwell and clinically complex. As such,
sessions for scheduled emergency surgery. For where clinically indicated, emergency surgery
example, emergency orthopaedic surgery at John patients should be prioritised ahead of elective
Hunter and Nepean Hospitals is planned from 8am surgical cases.
to 10pm, seven days a week. These strategies help
Patients requiring emergency surgery must be
to create sufficient theatre capacity to complete
assigned a clinical priority category to allow
emergency surgery cases within clinically
differentiation of urgency and prioritisation of
recommended timeframes and minimise adverse
theatre access. Assessment of clinical priority should
patient outcomes due to delayed surgery.
take into consideration:
Where standard-hours emergency surgery sessions
• the patient’s presenting clinical condition
are insufficient to meet demand, a number of options
can be explored. • comorbidities and overall physiological condition
• urgency of the surgical intervention
• Opening unused standard-hours theatre sessions.
• potential risk should the surgical intervention be
• Improving use of available standard-hours time
delayed.
through redesign of session start processes,
improving turnaround time, trainee supervision, The prioritisation framework in Table 1 differentiates
monitoring sessions overruns. urgency of emergency surgery, and should be
• Redistributing elective surgery to other hospitals applied to all patients requiring emergency surgery.
within the LHD or SHN. This framework provides a guide to prioritisation,
dependent on the needs of the individual patient and
• Removing non-surgical procedures from being
decision-making by their treating clinicians.
undertaken in operating theatres, for example,
colonoscopy, cystoscopy, hysteroscopy. Priority categories should be assigned by senior
• Reallocating a portion of after-hours resources to medical staff or consultants where possible, when
supplement standard-hours resources. the decision to have surgery is made and the patient
is listed on the theatre booking system. Where a
registrar is uncertain of the most appropriate
prioritisation category for a patient’s clinical
condition or there is a conflict, they must discuss with
the relevant specialist surgeon, obstetrician or
gynaecologist and anaesthetist.

Agency for Clinical Innovation 7 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

These categories represent the maximum timeframe 6. Emergency surgery models of care
in which a patient should receive emergency surgery,
are consultant-led
with every effort made to minimise waiting times
and facilitate access to theatres as soon as possible. Consultant-led surgical care models have been
shown to facilitate accurate diagnosis and rapid
Category A and B cases may also involve activating a
decision-making, improved clinical outcomes and
local clinical emergency risk system to minimise delays.
more efficient use of health resources. They also
An example of this is the trauma 'Code Crimson' facilitate standardised patient handover and
pathway; for trauma patients who are bleeding comprehensive supervision of surgical staff in
despite pre-hospital resuscitation by medical teams training.6,7
and require time-critical life-saving intervention.
Lack of involvement of consultants in emergency
Criteria for activation of the Code Crimson pathway is surgical patient care is associated with increased
persistent haemodynamic instability despite standard patient morbidity and mortality, increased average
trauma care, assessed as being secondary to ongoing time to surgery, increased length of stay and higher
haemorrhage in blunt or penetrating trauma. rates of surgery cancellation.7

Where patients are not medically fit for the proposed A number of consultant-led care models are
intervention, they are not ready for care and should established in NSW hospitals and across other
not be allocated an emergency priority category or jurisdictions.
added to the emergency surgery waiting list.
Hospitals with a dedicated emergency surgery team
Patients who are clinically assessed as not requiring should not reallocate team members to support
surgery within 72 hours, but who still require a delivery of elective surgery activity unless agreed to
surgical intervention, are categorised for an elective by the emergency surgery consultant for that day.
surgical procedure, in line with the NSW Health The circumstances necessitating this change should
Waiting Time and Elective Surgery Policy be documented as part of ongoing emergency
(PD2012_011).5 surgical workload monitoring and review processes.

Patients with hip fracture should be assigned Examples and additional detail regarding consultant-
Priority E or more urgent to facilitate surgical led models for emergency surgery, including the
intervention within 24 hours from the time of acute surgical unit model, are described in the
presentation to the treating hospital, unless there is Appendices of this Guideline.
a medical contraindication requiring management
prior to surgery. In cases where transfer from
another facility is required, the patient should
receive surgery within 48 hours from the time of
arrival at the presenting hospital.

Agency for Clinical Innovation 8 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

7. 
Evidence-based protocols are used 8. Local escalation plans are
for the assessment and treatment of established and agreed to
common acute surgical presentations facilitate delivery of best practice
patient care, communication and
Variation in assessment and treatment of common
conflict resolution
patient presentations is one of the main causes of
variation in outcomes for patients requiring All hospitals providing emergency surgery should
emergency surgical intervention. All hospitals should have escalation processes in place to support timely
assess and treat presenting patients using best decision-making, coordinated responses and
practice protocols and care pathways based on accountability with respect to managing demand,
contemporary, relevant evidence. including:
While these may require a degree of adaptation to • organisational capacity
make them suitable for the local clinical environment,
• patient prioritisation
the principles underpinning assessment and
treatment should be consistent with the available • cancellations and delays
evidence for best practice care. • patient transfer decision-making and coordination
• training and supervision
Implementation of event-driven protocols and
condition-specific care pathways will improve • conflict resolution.
predictability of patient journeys, facilitate training LHDs are responsible for meeting the care needs of
and education opportunities, and provide a patients within the district, including establishing
framework for discharge planning. They provide robust processes and communication pathways for
comprehensive guidance for medical, nursing, patient transfer between facilities to enable access to
surgical and allied health services, identifying the clinically appropriate care, and providing appropriate
agreed clinical leadership decisions of the involved treatment prior to transfer and upon return. Where a
specialists. patient cannot be safely or effectively managed
Pathways and protocols encourage continuity of within their current hospital, they must be transferred
care and enhance integration of management by to a facility that can adequately manage their
registrars, medical officers and case managers when condition. Delays to patient transfer negatively impact
individuals are transferring care. They also provide patient outcomes and contribute to inefficient
an effective mechanism by which hospitals can resource application and hospital bed block. 8,9
monitor and review variation in care, review Patient transfer protocols must be aligned with
conformity with agreed protocols, compare relevant NSW Health policy directives, including:
outcomes and take action to improve patient care.
• Critical Care Tertiary Referral Networks and
Transfer of Care (Adults) (PD2018_011)
• Critical Care Tertiary Referral Networks
(Paediatrics) (PD2010_030)
• Children and Adolescents – Inter-facility Transfers
(PD2010_031)

Agency for Clinical Innovation 9 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

• Children and Adolescents – Guidelines for Care in 9. A standardised set of indicators is

Acute Care Settings (PD2010_034)
applied to emergency surgery to
• Neonatal Consultation, Referral and Transfer facilitate service monitoring and
Arrangements in Collaboration with NETS
continuous quality improvement
(IB2020_015)
• NSW Inter-hospital Major Trauma Transfer Regular monitoring and review of emergency
Interim Guideline surgery performance is important to ensure quality
• Children and Adolescents – Admission to Service of care, patient outcomes and organisational
Designated Level 1-3 Paediatric Medicine & efficiency are measured.
Surgery (PD2010_032).10-16
Key performance measures relate to the overall
The decision to transfer must be based on the achievement of specific surgical performance targets
patient’s current clinical condition and prevailing and are reportable through local governance
local facility conditions. It must be made in channels to the NSW Ministry of Health.
consultation with relevant clinicians, including
Additional measures, such as demand, capacity and
surgeons and anaesthetists, at the referring and
process measures, also help to define the context of
receiving hospitals. Transparent and timely
a surgical service, tracking improvements, informing
communication between clinicians is vital, however,
service redesign and evaluating improvement
the final authority for decision-making rests with the
initiatives.
referring clinician.
A standardised set of emergency surgery indicators
For most emergency surgery patients, transfer to a
for NSW Health, reviewed on a regular basis, is
tertiary hospital within the same LHD will be suitable
recommended to facilitate service monitoring and
to meet their clinical needs. Where an LHD does not
continuous improvement. Table 2 outlines the factors
have a tertiary level facility, or a particular surgical
that should be incorporated into the minimum
specialty is not established, limitations of care
standardised indicator set.
available within the district should be documented.
For each such specialty service, a designated
responsible hospital or specialty unit must be agreed.
For identified limitations within a district, the Critical
Care Referral Networks apply, as per NSW Critical
Care Tertiary Referral Networks and Transfer of Care
(Adults) PD2018_011.10

Responsibilities under these referral networks must

be explicitly identified. To assist timely patient
transfer, an agreed referral plan should be established
for each specialty in the receiving hospital, and patient
transfers facilitated without delay.

Where a nominated hospital is unable to

accommodate the patient requiring transfer, the
agreed escalation plan should be initiated.

Agency for Clinical Innovation 10 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Table 2. Minimum standardised indicator set – emergency surgery

Indicator Metric

Emergency surgery load-balancing Proportion of theatre hours dedicated to emergency surgery

Performance according to emergency surgery Proportion of patients treated within the clinically indicated
prioritisation framework timeframe, in each urgency category
Supervision of registrars Proportion of theatre sessions in which the consultant surgeon
is in the operating suite
Average length of stay for index conditions Mean length of stay for emergency cholecystectomy,
fractured neck of femur, acute appendicitis
Out-of-hours surgery Proportion and number of emergency surgery cases
undertaken between 10pm and 6am
Postponement of emergency surgery cases Number of emergency surgery patients postponed

Average time to surgery for index conditions Mean time from arrival to entry to operating theatre for
fractured neck of femur, emergency caesarean section,
appendicectomy, cholecystectomy
Distribution of emergency surgery demand Proportion of emergency surgery demand across days of the
week, hours of the day, months of the year
Unplanned re-admissions following emergency surgery Proportion of patients re-admitted without prior planning
within 30 days of an emergency surgical intervention, by
specialty or by procedure
Appropriateness and safety of patient transfers Number of patients transferred to or from another facility for
emergency surgery, with specific focus on paediatric and
geriatric transfers
Monitoring patient transfers between facilities for
appropriateness, safety and efficiency is important to ensure
the most appropriate care is provided in the most appropriate
location
Transfers should also be reviewed and monitored regularly

Agency for Clinical Innovation 11 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Operational model

Agency for Clinical Innovation 12 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Surgical procedures
requiring urgent management

These examples, listed by specialty, may be applied for • Periorbital abscess associated with severe
both adult and paediatric patients where appropriate. proptosis or loss of visual acuity
• Quinsy
Colorectal • Some cases of ingestion of foreign bodies

• Impending ischaemia
General surgery
• Inflammatory bowel disease with toxic colon
• Large bowel obstruction – in the frail patient with • Acute abdomen
comorbidities • Gunshot and some cases of knife wounds
• Major retroperitoneal trauma • Haemorrhage
• Peritonitis – ruptured diverticulum • Intra-abdominal bleeding
• Septicaemia with radiologically undrainable abscess • Necrotising fasciitis (first presentation or
• Some cases of perianal abscess deteriorating patient)
• Perforated viscus including oesophagus,
Dental or faciomaxillary stomach, duodenum, small bowel, large bowel,
appendix and gall bladder
• Haemorrhage or mid-face bleeding
• Peritonitis
• Risk of inhalation (tooth or fragment)
• Return to theatre due to bleeding, especially
• Trauma associated with any of the above intra-abdominal
• Ruptured tumours
Ear, nose and throat (ENT)
• Severe necrotising infections
• Airway obstruction or airway compromise • Severe soft tissue infection causing sepsis
• Caustic and lye ingestion and some cases of • Severe or major intra-abdominal infection
smoke inhalation causing sepsis
• Diminishing visual acuity following endoscopic • Suspected ischaemic bowel
transeptal transsphenoidal surgery or endoscopic
sinus surgery Gynaecology
• Haematoma or infection causing reconstructive
flap compromise following major head and neck • Returns to theatre for bleeding
resections • Ectopic pregnancy with vascular instability
• Large cervical haematoma following surgery • Incomplete miscarriage with ongoing
• Nasal or mid-facial fractures with uncontrollable haemorrhage
haemorrhage or cerebrospinal fluid leak
• Neck or deep space abscesses
Hands
• Penetrating injuries, crush injury or gunshot • Amputations for reimplantation or
wounds affecting neck, larynx or airway revascularisation

Agency for Clinical Innovation 13 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Neurosurgery Orthopaedics
• Burr hole for insertion of extraventricular drain • Hip, femural, tibial, fibular, ankle and humeral
• Craniotomy for spontaneous intracerebral fracture
haematoma or any other intracranial conditions • Compartment syndrome
with imminent risk of 'coning' • Contaminated wounds
• Craniotomy for tumours that are causing critical • Dislocations
raised intracranial pressure
• Skin under tension
• Craniotomy to drain cerebral abscess
• Vascular compromise
• Trauma craniotomy for acute extradural, subdural
and intracerebral haematoma or penetrating
Paediatric
injuries and skull fractures
• Decompressive laminectomy or other spinal • Severe gastrointestinal bleeding
operations for cord or cauda equina compression, • Abscess with systemic sepsis
caused by trauma, large disc herniations or infection
• Exsanguinating haemorrhage
• Necrotising enterocolitis
Obstetrics
• Necrotising fasciitis
• Prolapsed cord • Penetrating trauma
• Ruptured uterus • Perforated hollow viscus
• Caesarean sections • Return to theatre for transplants with bleeding or
• Major obstetrics tear +/- 4th degree tear vascular occlusion
• Postpartum haemorrhage • Severe blunt trauma
• Trial of forceps • Torsion of testis
• Peritonitis
Ophthalmology • Trauma associated with haemorrhage – vascular
instability despite 50% blood volume
• Acute glaucoma (very high intraocular pressure) replacement (crystalloid or colloid) in first two
not adequately controlled by medical treatment hours, or after whole blood +50% blood volume
• Penetrating eye injuries requiring exploration of crystalloid or colloid
• Repair of eyelid and periocular facial or orbit • Ureteric avulsion
injuries and fractures (compound especially) • Urethral rupture
• Retinal detachment repair (including vitrectomy)
required for impending or recent ‘macular off’ Plastics
retinal detachment
• Vitrectomy for severe cases of infective • Free flaps requiring return to theatre
endophthalmitis • Impending nerve compromise due to fracture
• Orbital exploration or abscess drainage for orbital dislocation
cellulitis

Agency for Clinical Innovation 14 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Urology
• Complete anuria due to ureteric obstruction
• Complications arising from laparoscopic
urological surgery to upper or lower urinary tract
or genital tract
• Exsanguinating renal injuries
• Fournier's gangrene
• Gunshot wounds or penetrating injuries involving
the urinary tract
• Injury to urinary tract in conjunction with other
intra-abdominal trauma
• Intraperitoneal bladder rupture
• Rupture of membranous urethra in conjunction
with pelvic fracture
• Severe clot retention in the bladder
• Testicular torsion
• Ureteric avulsion

Vascular
• Abdominal aortic aneurysm
• Grafts requiring revascularisation
• Haemorrhage (including returns to theatre and
other specialty operations requiring vascular
assistance)
• Organ donation and harvest
• Some cases of fistula formation

Agency for Clinical Innovation 15 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

 pplication of the urgency prioritisation

A
framework to common emergency general
surgical presentations
The tables in this section outline recommended used as guide only, for consideration alongside
urgency prioritisation categories for common clinical judgement and individualised risk
emergency general and obstetric surgery assessment.
presentations. These recommendations should be

Table 3. R
 ecommended urgency prioritisation categories for common emergency general surgical
presentations

Clinical priority

Highly Critical
Life threatening (including organ /
Clinical (including limb threatening) Semi-urgent
condition obstetric) (<1hr) (<2hr) Critical (<4hrs) Urgent (<8hrs) (<24hrs)

Abscess Proven or clinically Advanced local Uncomplicated

suspected infection without abscess
necrotising soft septic shock
tissue (including Abscess with
Fournier’s surrounding cellulitis
gangrene) in a diabetic or
infection, with immunocompromised
hypotension, patient
impaired renal
function

Appendicitis Perforation Perforation clinically Clinically

with peritonitis, or radiologically, suspected or
hypotensive tachycardic, elevated radiologically
Patients with C-reactive protein, proven without
septic shock* that but normotensive tachycardia
require source Clinical appendicitis
control with peritonism
localised to right iliac
fossa

Cholecystitis Cholecystitis with Severe sepsis, or Clinical

perforated gall suspected necrosis, cholecystitis
bladder and biliary with tachycardia, confirmed on
peritonitis, or fever radiology imaging,
severe sepsis* with Cholecystitis systemically well
shock with right upper
quadrant pain,
localised peritonism,
or diabetic or
immunocompromised
without hypotension

* Sepsis and septic shock in line with qSOFA criteria; low blood pressure, high respiratory rate and altered mental status.17

Agency for Clinical Innovation 16 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Clinical priority

Highly Critical
Life threatening (including organ /
Clinical (including limb threatening) Semi-urgent
condition obstetric) (<1hr) (<2hr) Critical (<4hrs) Urgent (<8hrs) (<24hrs)

Diverticulitis Severe shock with Free perforation with Rising C-reactive

free perforation, at least localised protein, fever in
hypotensive peritonitis but no a patient with
haemodynamic mesenteric air who
instability is not responding
to antibiotics
Diverticular
phlegmon on CT
failing to improve
on antibiotics,
normotensive

Fracture Compound fracture Hip fracture

Hernia Irreducible hernia Irreducible hernia Irreducible hernia

involving bowel involving bowel, without bowel
with evidence including obstruction involvement
of perforation or but no evidence of
necrosis perforation or skin
cellulitis

Obstetric Sustained fetal Bleeding placenta Spontaneous

emergencies bradycardia, previa with stable rupture of
cord prolapse, maternal and fetal membranes (not
uterine rupture, observations, other in labour), breech
postpartum non-immediately presentation
haemorrhage, life threatening in early labour,
retained placenta, maternal and fetal fulminating
abnormal scalp pH concerns pre-eclampsia
(<7.2) or lactate

Small bowel Exsanguinating Small bowel Small bowel Small bowel

adhesions gastrointestinal obstruction with obstruction obstruction
haemorrhage perforation, and with closed loop with persisting
hypotension obstruction or abdominal pain,
suspected ischaemic haemodynamically
bowel, without stable
haemodynamic Small bowel
compromise obstruction
persisting after
a period of
non-operative
treatment

Soft tissue Necrotising

infection fasciitis

Vascular Ruptured
abdominal aortic
aneurysm
Critically ischaemic
leg

Agency for Clinical Innovation 17 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Redesigning clinical services

Emergency surgery management requires Alignment of resources and theatre session planning
appropriate planning for workload, workforce and are also associated with improved theatre utilisation,
resources. It takes into account the unique threats to a reduction in elective surgery cancellations, and
life, limb and organ function faced by patients, with increased access to standard hours theatre
risk of these threats increasing in the event of delays sessions.
to treatment.
Improved theatre planning also positively impacts
Redesigning emergency surgery services requires other hospital resources such as intensive care,
an active partnership between clinicians and radiology and pathology services. The use of agreed
managers, with time and commitment needed from protocols and pathways standardises requests for
surgeons, operating theatre staff, surgical heads of diagnostic tools and facilitates better planning of
department and hospital or district executive critical care resources.
leaders.

Effective redesign of emergency surgery services

Process of designing and delivering
comprises three discrete phases. emergency surgery in NSW hospitals

1. Operational reconfiguration to optimise theatre Assess surgical load

scheduling; elective and emergency workload
• Review the demand for emergency surgery in
balance; designation of hospitals for elective or
the LHD.
emergency surgery or components of each;
allocation of theatre resources matched to • Assess emergency surgery demand by hospital
workload; and reallocation of resources to match and by specialty.
designated hospital role delineations.
Calculate session requirements
2. Specific clinical models for emergency surgery
management are selected to best suit the hospital • Estimate the number of theatre sessions, or
and its emergency surgery volume. theatre minutes, required to meet emergency
3. Evidence-based protocols are identified and surgery demand in standard operating hours.
implemented for the assessment and treatment of Input from surgeons and hospital managers will
common emergency surgery presentations. be needed to determine this.
• Calculate the standard-hours theatre sessions, by
Redesigning emergency surgery services results in
specialty, required for the emergency surgery load.
enhanced clinical performance, effective service
management and improved resource utilisation. • Recognise that a small proportion of emergency
Consultant-led models of care are associated with surgery load will likely be undertaken out of
reduced patient morbidity and mortality, while standard operating hours.
improved predictability of access to surgery
improves both patient and staff satisfaction, as well
as enhanced oversight by senior clinicians.

Agency for Clinical Innovation 18 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Role delineation of hospitals Establish patient transfer protocols

• Review the Guide to the Role Delineation of • Establish local protocols to manage patient
Clinical Services (2019).18 transfers between hospitals, in line with
• Define the appropriate level of surgical statewide policies and local procedures.
complexity in each facility.
Implement evidence-based protocols and
• Designate hospitals within the LHD as
pathways
undertaking elective surgery, emergency surgery
or both. • Determine processes for emergency surgery case
management, including:
Select the appropriate model of care
− patient management pathways for common
• Select a model of care for emergency surgery, emergency surgery presentations
taking into account the hospital role, surgical load − processes for handover of patient care
and complexity. − options for continuing ongoing care after on-call
• Determine the surgical conditions and period
procedures, by specialty, that can safely wait to − process for managing inpatient consultations
be performed in standard-hours.
− patient follow-up after discharge.

Align elective and emergency loads Communication planning

• Allocate the required theatre sessions or theatre • Communicate care models, processes and
minutes to meet the hospital demand for protocols for emergency surgery management to:
emergency surgery, in standard operating hours.
− district and hospital staff
• Offset elective and non-emergency theatre
− the local community and patients
sessions to accommodate emergency surgery in
− general practices and aged care providers
standard hours.
− NSW Ambulance.
Reallocate resources

• Ensure resources are reallocated, if required, to

accommodate the designated emergency
surgery sessions. This includes equipment, staff
and technology.
• Determine consultant surgeon roster pattern,
procedure for roster changes and cover for
planned and unplanned leave.

Agency for Clinical Innovation 19 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Models of emergency surgery care

Acute surgical unit The ASU:

• is generally assigned a dedicated registrar or

Much of the recent published literature has focused on
fellow, resident medical officer(s) and clinical
the effectiveness of acute surgical unit (ASU),
nurse consultant
particularly when compared with the ‘traditional’
model of care, whereby emergency surgery is • ideally comprises designated beds or wards for
managed as cases arise on an ad hoc basis. The ASU patient assessment and management
is often applied in general surgery, but warrants • includes a minimum of daily multidisciplinary
consideration by other surgical specialties, in team rounding
particular, orthopaedic surgery. It is consultant-led, • has formalised handover processes between
with surgeons limiting or relinquishing all competing incoming and outgoing on-call consultant
commitments during their on-call period, including surgeons, with information based on a standard
private sector operating and consulting. Additionally, set of key principles
there are dedicated emergency surgery theatre
• ideally has a consistent team and functions seven
sessions scheduled to enable rapid access for ASU
days per week
patients.
• provides priority outpatient access for emergency
While ASUs may be organised in a variety of ways, surgery patient assessments
the literature identifies three key features: • has agreed clinical guidelines in place for
common emergency general surgery
• a 24-hour service for acute surgical conditions
presentations
• a consultant onsite dedicated to emergency
• has a formalised process for follow-up of ASU
surgery management
patients.
• separated emergency and elective surgery lists.
A review of literature relating to ASUs and similar
The on-call consultant:
models of care internationally have found
• is onsite during standard-hours implementing such units reduces:

• is rostered on for a period of at least 24 hours • length of stay

• oversees case priority for these sessions • time from presentation to operation
• is present, teaching and supervising when • the number of surgeries performed after hours
surgery is being performed
• complication rates.19-22
• conducts daily rounds of the patients in the ASU
These benefits are attributable to increased
• provides consultation services for inpatients
consultant supervision and a reduced number of
requiring emergency surgical review and
assessment.

Agency for Clinical Innovation 20 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

surgeries occurring outside of regular hours. Specialist centralisation model

Reduced waiting times and reduced surgery outside
of regular hours also increases availability of Under this model, certain specialty services for a
surgeons, given a consultant is allocated to focus on district are consolidated at a single facility.
emergency surgery. Reduced waiting time also Concentrating resources in one facility within the
contributes to a reduced length of stay. district or geographic location means increased
availability of specialist surgeons at that facility. This
The ASU model ensures availability of a consultant
means they are better equipped to deal with
surgeon, increasing senior clinician involvement in
emergency presentations.
patient management and treatment decisions, and
facilitates consultant-to-consultant case review. This model operates under a volume-outcome
Surgeons’ conflicting priorities are minimised and assumption, whereby an increase in the volumes of
junior staff have greater learning opportunities. emergency procedures undertaken correlates to
Patient outcomes are improved through improved patient outcomes for the cohort. However,
standardised patient handover and follow-up, it is important to note that volume is one of many
increased surgical resident and registrar supervision, factors influencing outcomes.
reduced after-hours operating time and opportunity
While network arrangements for service delivery
to appoint appropriately skilled surgeons who make
can enhance collaboration between facilities and
substantial contributions to emergency surgical
increase efficiency, fragmentation of care and
services.
decreased workforce capabilities may also arise.

Sub-specialty model
Surgical assessment unit
The focus of this model is to have emergency
A surgical assessment unit (SAU) is a specialised
surgery patients managed by consultants from the
unit that provides a fast track route for the
relevant subspecialty. This is different from the ASU
assessment of acute adult surgical patients. The
model, where the consultant is often a general
SAU reviews and/or admits stable patients from the
surgeon.
emergency department, direct admissions from
Under the subspecialty model, patients are admitted outpatients and visiting medical officers rooms,
under the relevant subspecialty team. While limited inter-hospital transfers, and weekend and public
evidence to support this model is published, holiday presentations.
preliminary results indicate that streamlined access
The SAU provides a focal point for emergency
to specialist care may lead to reduced length of stay
surgical admissions in the hospital, providing rapid
(as fewer open procedures are undertaken) and
assessments by senior medical staff followed by
reduced post-operative complications due to
prompt investigations and treatment or discharge.
enhanced access to specialist expertise.
The service enables all surgical specialties
(excluding obstetrics and gynaecology, neurosurgery
and cardiothoracic) to be assessed and admitted or
discharged as appropriate.

Agency for Clinical Innovation 21 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Operating theatre session planning

Options for scheduling theatre sessions are Designated emergency surgery

influenced by a number of factors, including the
sessions, single specialty (full day or
availability of surgical time, staff and anticipated
partial day)
emergency surgical load. The options listed in this
section are not exhaustive, and alternative session Suitable for sufficient surgical load. This requires
models may be found more suitable for local availability of the appropriate surgeon to fully utilise
conditions. the session. This is particularly suitable for
emergency general and orthopaedics surgery.
Mixed emergency and elective
sessions Advantages

Suitable where emergency load and case complexity • Evidence for reduced waiting time, length of stay
are low. Sessions must be planned to accommodate and improved patient outcomes
the expected emergency cases, and any variation in • Training opportunities and professional
workload could be covered by short notice elective development capability
cases. This is particularly suitable for planning of • Certainty of rostering for staff
emergency caesarean sections into gynaecology
lists. Disadvantages

Advantages • Reduced flexibility compared to mixed sessions

(elective, emergency or mixed specialty)
• Increased utilisation of elective session capacity
• Dependant on emergency surgery workload and
• Increased flexibility for emergency management case mix

Disadvantages

• Reduced access to specialist consultant surgeons

• Increased potential for competition between
elective and emergency surgery priorities

Agency for Clinical Innovation 22 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Designated emergency surgery Designated emergency twilight

sessions with mixed specialties sessions (after 5pm hours)
(full day or partial day)
Provides the option for emergency surgery outside
Suitable where emergency load and case complexity of traditional operating hours (8am-5pm), facilitating
are low. Emergency surgery is allocated a set patient preparation during the day and increased
amount of time across a day or weekly schedule, surgeon availability from late afternoon.
allowing patients to be booked according to clinical
urgency without disruption to elective lists. Advantages

• Increased capacity for standard-hours surgery

Advantages
• Increased capacity for consultant-led sessions
• Evidence for reduced waiting time, length of stay • Flexibility for demand management with
and improved patient outcomes quarantined resources
• Creation of ‘Emergency Surgery Team’ with
enhanced supervision and training opportunities Disadvantages
• Builds general surgical capabilities
• Can create delays in time to theatre where no
morning sessions for emergency surgery are
Disadvantages
available
• Staff mix or allocation can be challenging to meet • Support services (imaging, pathology) are not
individual patient needs always available during twilight hours
• Reduced access to specialist surgeons
• Can be difficult to implement due to requirement
to coordinate multiple consultants

Agency for Clinical Innovation 23 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

References

1. Royal Australasian College of Surgeons. Position 9. Wong K, Levy RD. Interhospital transfers of
paper on emergency surgery 2015 [Internet]. patients with surgical emergencies: areas for
Available from: https://umbraco.surgeons.org/ improvement. Aust J Rural Health.
media/1643/2015-05-20_pos_fes-pst-050_ 2005;13(5):290-294.
emergency_surgery.pdf doi:10.1111/j.1440-1584.2005.00719.x
2. NSW Ministry of Health. Activity based 10. NSW Ministry of Health. NSW critical care
management portal [Internet]. Sydney: NSW tertiary referral networks and transfer of care
Health; 2020. (adults) (PD2018_030). Sydney: NSW Health;
2018. Available from: https://www1.health.nsw.
3. NSW Ministry of Health. EDWARD support site.
gov.au/pds/ActivePDSDocuments/PD2018_011.
Sydney: NSW Health; 2020.
pdf
4. Queensland Government. Emergency surgery
11. NSW Ministry of Health. Critical care tertiary
access guideline [Internet]. Department of
referral networks (paediatrics) (PD2010_030).
Health; 2017.
Sydney: NSW Health; 2010. Available from:
5. NSW Ministry of Health. Waiting time and https://www1.health.nsw.gov.au/pds/Pages/
elective surgery policy (PD2012_11). Sydney: doc.aspx?dn=PD2010_030
NSW Health; 2012. Available from: https://
12. NSW Ministry of Health. Children and
www1.health.nsw.gov.au/pds/Pages/doc.
adolescents - inter-facility transfers
aspx?dn=PD2012_011
(PD2010_031). Sydney: NSW Health; 2010.
6. Academy of Medical Royal Colleges. Benefits of Available from: https://www1.health.nsw.gov.
consultant delivered care. London, United au/pds/Pages/doc.aspx?dn=PD2010_031
Kingdom: Academy of Medical Royal Colleges;
13. NSW Ministry of Health. Children and
2012. Available from: https://www.aomrc.org.uk/
adolescents – guidelines for care in acute care
wp-content/uploads/2016/05/Benefits_
settings (PD2010_034). Sydney: NSW Health;
consultant_delivered_care_1112.pdf
2010. Available from: https://www1.health.nsw.
7. Shakerian R, Thomson BN, Gorelik A, et al. gov.au/pds/Pages/doc.aspx?dn=PD2010_034
Outcomes in emergency general surgery
14. NSW Ministry of Health. Neonatal consultation,
following the introduction of a consultant-led
referral and transfer arrangements in
unit. Br J Surg. 2015;102(13):1726-1732.
collaboration with NETS (IB2020_015). Sydney:
doi:10.1002/bjs.9954
NSW Health; 2020. Available from: https://
8. Clinical Excellence Commission. Clinical focus www1.health.nsw.gov.au/pds/Pages/doc.
report from review of root cause analysis and/or aspx?dn=IB2020_015
incident information management system (IIMS)
15. NSW Agency for Clinical Innovation. NSW
data retrieval and inter-hospital transfer. Sydney:
inter-hospital major trauma transfer interim
CEC; 2013. Available from http://www.cec.
guideline. Sydney: ACI; 2019. Available from:
health.nsw.gov.au/__data/assets/pdf_
https://www.aci.health.nsw.gov.au/get-involved/
file/0019/259210/patient-safety-report-
institute-of-trauma-and-injury-management/
retrieval-and-inter-hosp-trans-web.pdf
clinical/trauma-guidelines/Guidelines/nsw-inter-
hospital-major-trauma-transfer-interim-
guideline

Agency for Clinical Innovation 24 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

16. NSW Ministry of Health. Children and

adolescents – admission to service designated
level 1-3 paediatric medicine & surgery
(PD2010_032). Sydney: NSW Health; 2010.
Available from: https://www1.health.nsw.gov.
au/pds/Pages/doc.aspx?dn=PD2010_03
17. UPMC, University of Pittsburgh, CRISMA Center.
Quick sepsis related organ failure assessment:
What is qSOFA? [Internet]. qSOFA. Available
from: https://www.qsofa.org/what.php

18. NSW Ministry of Health. Guide to the role

delineation of clinical services (2019). 4th ed.
Sydney; NSW Health; 2019.

19. Kinnear N, Bramwell E, Frazzetto A, et al. Acute

surgical unit improves outcomes in
appendicectomy. ANZ J Surg. 2019;89(9):1108-
1113. doi:10.1111/ans.15141

20. Shilton H, Tanveer A, Poh BR, et al. Is the acute

surgical unit model feasible for Australian
regional centres?. ANZ J Surg. 2016;86(11):889-
893. doi:10.1111/ans.13724

21. Navarro AP, Hardy E, Oakley B, et al. The front-

line general surgery consultant as a new model
of emergency care. Ann R Coll Surg Engl.
2017;99(7):550-554. doi:10.1308/
rcsann.2017.0081

22. Rance C, Richards SK, Jones AE. Front door

surgeons: the rise of consultant-delivered acute
surgical care. Br J Gen Pract. 2016;66(646):234-
235. doi:10.3399/bjgp16X684889

23. NSW Agency for Clinical Innovation Institute of

Trauma and Injury Management. Trauma 'Code
Crimson' pathway: ACI; 2017. Available from https://
aci.health.nsw.gov.au/__data/assets/pdf_
file/0003/382917/Trauma-Code-Crimson-
Pathway-Final-20170919.pdf

Agency for Clinical Innovation 25 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Additional evidence

• Australian and New Zealand College of • Queensland Dept of Health. Emergency surgery
Anaesthetists. Guidelines for transport of access (QH-GDL-440:2017). QLD Health; 2017.
critically ill patients (PS52). Melbourne: ANZCA; Available from: https://www.health.qld.gov.
2015. au/__data/assets/pdf_file/0033/635784/qh-
gdl-440.pdf
• Chana P, Burns EM, Arora S, et al. Systematic
review of the impact of dedicated emergency • Russell A, Havranek E, Webster J, et al. Consultant-
surgical services on patient outcomes. Ann Surg. delivered care – what is it worth? Bull Roy Coll Surg
2016 Jan;263(1):20-7. doi: 10.1097/ Engl. 2015 Jul;97(7):e22-5. doi: 10.1308/
SLA.0000000000001180. rcsbull.2015.e22
• Clinical Excellence Commission. Recognition and • The Royal Australian and New Zealand College of
management of patients who are deteriorating Obstetricians and Gynaecologists. Categorisation
(PD2020_018). Sydney: NSW Ministry of Health; of urgency for caesarean section. Melbourne: The
2020. Available from https://www1.health.nsw. Royal Australian and New Zealand College of
gov.au/pds/Pages/doc.aspx?dn=PD2020_018 Obstetricians and Gynaecologists; 2019.
Available from: https://ranzcog.edu.au/
• Collins C, Pringle L, Santry H. Innovation or
RANZCOG_SITE/media/RANZCOG-MEDIA/
rebranding: acute care surgery diffusion will
Women%27s%20Health/Statement%20and%20
continue. J Surg Res. 2015 Aug;197(2):354-62.
guidelines/Clinical-Obstetrics/Categorisation-of-
doi: 10.1016/j.jss.2015.03.046
urgency-for-caesarean-section-(C-Obs-14).
• Ingraham AM, Ayturk MD, Kiefe CI, et al. (2018). pdf?ext=.pdf
Adherence to 20 emergency general surgery best
• Tomlinson JH, Lucas DN. Decision-to-delivery
practices: results of a national survey. Ann Surg.
interval: Is 30 min the magic time? What is the
2019 Aug;270(2):270-80. doi: 10.1097/
evidence? Does it work?. Best Pract Res Clin
SLA.0000000000002746.
Anaesthesiol. 2017;31(1):49-56. doi:10.1016/j.
• Nagaraja V, Eslick GD, Cox MR. The acute bpa.2017.04.001
surgical model versus the traditional 'on-call'
model: a systematic review and meta-analysis.
World J Surg. 2014 Jun;38(6):1381-7. doi: 10.1007/
s00268-013-2447-1.
• NSW Ministry of Health. Inter-facility transfer
process for adults requiring specialist care
(PD2011_031). Sydney: NSW Health; 2011.
Available from: https://www1.health.nsw.gov.au/
pds/Pages/doc.aspx?dn=PD2011_031

Agency for Clinical Innovation 26 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Glossary

Consultant  registered medical professional who has been assessed by an Australian Medical
A
Council-accredited specialist college as having the necessary qualifications in the
approved specialty to be included on the Specialist Register.

Elective surgery  lective care is care that, in the opinion of the treating clinician, is necessary and
E
admission for which can be delayed for at least 24 hours. Elective surgery patients are
generally booked onto the elective surgery waiting list and their surgical requirements
provided on a completed Recommendation for Admission form. These patients may also
be described as planned or booked patients.

Emergency surgery Surgery to treat trauma or acute illness subsequent to an emergency presentation. The
patient may require immediate surgery or present for surgery at a later time following
this unplanned presentation. This includes where the patient leaves hospital and returns
for a subsequent admission. Emergency surgery includes unplanned surgery for admitted
patients and unplanned surgery for patients already awaiting an elective surgery
procedure (for example, in cases of acute deterioration of an existing condition).

Handover 
The transfer of professional responsibility and accountability for some or all aspects of
care for a patient from one person or professional group to another, on a temporary or
permanent basis.

Obstetric
emergencies The definitions applied to caesarean sections in obstetrics differs from other definitions
of surgical emergencies as follows.

An elective caesarean is a section in a non-labouring woman.

An elective caesarean may be urgent.
An emergency caesarean is a section in a labouring woman.
An emergency caesarean section is sometimes non-urgent.

Out-of-hours 
The period of time outside of the hospital’s defined standard hours. During this time,
many hospital services are closed, operating on minimal staffing levels or on a call-back
system.

Receiving hospital The hospital to which a patient is transferred, generally to receive a higher level of care
than can be provided by the referring hospital.

Referring hospital A hospital from which a patient needs to be referred and transferred in order to access a
higher level of care.

Standard hours The period in daylight hours in which most hospitals have the maximum number of
services operational and have the highest staffing levels. This is often 8am-5pm Monday
to Friday, however, weekend and twilight (up to 10pm) standard hours are becoming
more common. The majority of surgical operations are scheduled in standard hours.

Agency for Clinical Innovation 27 www.aci.health.nsw.gov.au

NSW emergency surgery guidelines and principles for improvement February 2021

Acknowledgements

The NSW Emergency Surgery Guidelines were In 2018-19, a working group was established to
originally developed in 2009 by a subgroup of the revise the NSW Emergency Surgery Guidelines. This
Surgical Services Taskforce led by Professor multidisciplinary group included significant clinical
Stephen Deane. and managerial expertise across surgery,
anaesthesia, nursing, paediatrics and obstetrics.
Acknowledging the complexity and volume of
emergency surgery undertaken across all surgical The Agency for Clinical Innovation wishes to thank
specialties, the guidelines encouraged hospitals to all members of the working group for their time and
plan ahead for the predictable emergency surgical generosity in sharing their expertise and experiences
workload. The guidelines also assisted hospitals to to inform this iteration of the NSW Emergency
review their past workloads, assess anticipated Surgery Guidelines and Principles for Improvement.
future demands and allocate appropriate resources.

Agency for Clinical Innovation 28 www.aci.health.nsw.gov.au

The Agency for Clinical Innovation (ACI) is
the lead agency for innovation in clinical care.

We bring consumers, clinicians and

healthcare managers together to support
the design, assessment and implementation
of clinical innovations across the NSW public
health system to change the way that care
is delivered.

The ACI’s clinical networks, institutes and

taskforces are chaired by senior clinicians
and consumers who have a keen interest
and track record in innovative clinical care.

We also work closely with the Ministry of

Health and the four other pillars of NSW
Health to pilot, scale and spread solutions
to healthcare system‑wide challenges.
We seek to improve the care and outcomes
for patients by re‑designing and transforming
the NSW public health system.

Our innovations are:

• person‑centred
• clinically‑led
• evidence‑based
• value‑driven.

www.aci.health.nsw.gov.au

Our vision is to create the future of healthcare,

and healthier futures for the people of NSW.