Impact of acute care surgery model in aspects of patients with upper gastrointestinal hemorrhage: result from a single tertiary care center in Thailand

BACKGROUND: Even though an acute care surgery (ACS) model has been implemented worldwide, there are still relatively few studies on its efficacy in developing countries, which often have limited capacity and resources. To evaluate ACS efficacy in a developin country, we compared mortality rates and intervention timeliness at a tertiary care center in Thailand among patients with an upper gastrointestinal hemorrhage (UGIH). METHODS: This retrospective study compared two 24-month periods between pre-ACS and post-ACS implementations from July 1, 2014, to June 30, 2018. Medical records from consecutive patients with UGIH in the surgical department of Chonburi Hospital, Thailand, were reviewed. The primary outcome was UGIH mortality rate differences between pre-ACS and post-ACS implementations. Differences in complications rate, length of hospital stay (LOS), time to esophagogastroduodenoscopy (EGD) and proportion of patients undergoing esophagogastroduodenoscopy (%EGD) in the same admission were also analyzed using unpaired t-test and Fisher’s exact test. Baseline characteristic differences between the pre-ACS and post-ACS periods were controlled for in multiple linear and logistic regression models. RESULTS: A total of 421 patients were included (162 pre-ACS and 259 post-ACS). Results showed a mortality rate of 24% in post-ACS compared with 41% in pre-ACS period (p<0.001). Overall complications (38% vs 27%), LOS (6.4 days vs 5.6 days) and time to EGD (44 hours vs 25 hours) were also significantly reduced, whereas %EGD increased (70% vs 89%). After adjusting for covariates, patients in the post-ACS period had lower risk of death (OR 0.54, p=0.040), lower risk of developing respiratory complications (OR 0.52, p=0.036), higher chance of receiving EGD in the same admission (OR 2.94, p<0.001) and shortened time to EGD for 19 hours (p<0.001). DISCUSSION: Our results provide evidence that ACS can be implemented to improve patient outcomes at medical centers in developing countries with limited resources. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.