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Coffey EK, Walker RM, Nicholson P, Gillespie BM. Prioritising patients for semi-urgent surgery: A scoping review. J Clin Nurs 2024; 33:2509-2524. [PMID: 38334175 DOI: 10.1111/jocn.17056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/16/2023] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Semi-urgent surgery where surgical intervention is required within 48 h of admission and the patient is medically stable is vulnerable to scheduling delays. Given the challenges in accessing health care, there is a need for a detailed understanding of the factors that impact decisions on scheduling semi-urgent surgeries. AIM To identify and describe the organisational, departmental and contextual factors that determine healthcare professionals' prioritising patients for semi-urgent surgeries. METHODS We used the Joanna Briggs Institute guidance for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR) checklist. Four online databases were used: EBSCO Academic Search Complete, EBSCO Cumulative Index to Nursing and Allied Health Literature, OVID Embase and EBSCO Medline. Articles were eligible for inclusion if they published in English and focussed on the scheduling of patients for surgery were included. Data were extracted by one author and checked by another and analysed descriptively. Findings were synthesises using the Patterns, Advances, Gaps, Evidence for practice and Research recommendations framework. RESULTS Twelve articles published between 1999 and 2022 were included. The Patterns, Advances, Gaps, Evidence for practice and Research recommendations framework highlighted themes of emergency surgery scheduling and its impact on operating room utilisation. Gaps in the management of operating room utilisation and the incorporation of semi-urgent surgeries into operating schedules were also identified. Finally, the lack of consensus on the definition of semi-urgent surgery and the parameters used to assign surgical acuity to patients was evident. CONCLUSIONS This scoping review identified patterns in the scheduling methods, and involvement of key decision makers. Yet there is limited evidence about how key decision makers reach consensus on prioritising patients for semi-urgent surgery and its impact on patient experience. PATIENT OR PUBLIC CONTRIBUTION No Patient or Public Contribution.
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Affiliation(s)
- Elyse K Coffey
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| | - Rachel M Walker
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- Division of Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| | - Patricia Nicholson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Brigid M Gillespie
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- Gold Coast University Hospital, Gold Coast Health Nursing and Midwifery Education and Research Unit, Gold Coast, Queensland, Australia
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Laane CL, Van Lieshout EM, Van Heeswijk RA, De Jong AI, Verhofstad MH, Wijffels MM. Validity of the ACS NSQIP surgical risk calculator as a tool to predict postoperative outcomes in subacute orthopedic trauma diagnoses. Heliyon 2024; 10:e25796. [PMID: 38375267 PMCID: PMC10875421 DOI: 10.1016/j.heliyon.2024.e25796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 01/27/2024] [Accepted: 02/02/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose This retrospective study aimed to validate the ACS NSQIP Surgical Risk Calculator (SCR) to predict 30-day postoperative outcomes in patients with one of the following subacute orthopedic trauma diagnoses; multiple rib fractures, pelvic ring/acetabular fracture, or unilateral femoral fracture. Methods Data of patients with these diagnoses treated between January 1, 2015 and September 19, 2020 were extracted from the patients' medical files. Diagnostic performance, discrimination, calibration, and accuracy of the ACS NSQIP SRC to predict specific outcomes developing within 30 days after surgery was determined. Results The total cohort of the three diagnoses consisted of 435 patients. ACS NSQIP SRC underestimated the risk for serious complications, especially in patients with multiple rib fractures (8.3% predicted vs 17.2% observed) or pelvic ring/acetabular fracture (6.1% vs 19.8%). Underestimation was more pronounced for the composite outcome 'any complication'. Sensitivity ranged from 16.7% to 100% and specificity from 41.1% to 97.1%. Specificity exceeded sensitivity for pelvic ring/acetabular and femoral fractures. Discrimination was good for predicting death (femoral fracture), fair for readmission (femoral fracture), serious complication (multiple rib fractures), and any complication (multiple rib fractures), but poor in all other outcomes and diagnoses. Calibration and accuracy were adequate for all three diagnoses (p-value for Hosmer-Lemeshow test >0.05 and Brier scores <0.25). Conclusion Performance of the ACS NSQIP SRC in the studied cohort was variable for all three diagnoses. Although it underestimated the risk of most outcomes, calibration and accuracy seemed generally adequate. For most outcomes, adequate diagnostic performance and discrimination could not be confirmed.
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Affiliation(s)
| | - Esther M.M. Van Lieshout
- Corresponding author. Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Roos A.M. Van Heeswijk
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Amber I. De Jong
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Michael H.J. Verhofstad
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mathieu M.E. Wijffels
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Jalava K, Sallinen V, Lampela H, Malmi H, Steinholt I, Augestad KM, Leppäniemi A, Mentula P. Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trial. Lancet 2023; 402:1552-1561. [PMID: 37717589 DOI: 10.1016/s0140-6736(23)01311-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Appendicectomy remains the standard treatment for appendicitis. No international consensus exists on the surgical urgency for acute uncomplicated appendicitis, and recommendations vary from surgery without delay to surgery within 24 h. Longer in-hospital delay has been thought to increase the risk of perforation and further morbidity. Therefore, we aimed to compare the rate of appendiceal perforation in patients undergoing appendicectomy scheduled to two different urgencies (<8 h vs <24 h). METHODS In this pragmatic, open-label, multicentre, non-inferiority, parallel, randomised controlled trial in two hospitals in Finland and one in Norway, patients (aged ≥18 years) with presumed uncomplicated acute appendicitis were randomly assigned (1:1) to an appendicectomy scheduled within 8 h or within 24 h to determine whether longer in-hospital delay (time between randomisation and surgical incision) is not inferior to shorter delay. Patients were excluded in cases of pregnancy, suspicion of perforated appendicitis (C-reactive protein level of ≥100 mg/L, fever >38·5°C, signs of complicated appendicitis on imaging studies, or clinical generalised peritonitis), or other reasons requiring prompt surgery. The recruiters were on-duty surgeons who decided to proceed with the appendicectomy. The randomisation sequence was generated using block randomisation with randomly varying block sizes and stratified by hospital districts; neither physicians nor patients were masked to group assignment. The primary outcome was perforated appendicitis diagnosed during surgery analysed in all patients who received an appendicectomy by intention to treat. The absolute difference in rates of perforated appendicitis was compared between the groups. Complications and other safety outcomes were analysed in all patients who received an appendicectomy. A margin of 5 percentage points was used to establish non-inferiority. This trial was registered at ClinicalTrials.gov (NCT04378868) and is closed to accrual. FINDINGS Between May 18, 2020, and Dec 31, 2022, 2095 patients were assessed for eligibility, of whom 1822 were randomly assigned to appendicectomy scheduled within 8 h (n=914) or 24 h (n=908). After randomisation, 19 (1%) of 1822 patients were excluded due to protocol violation. 1803 patients were included in the intention-to-treat analyses, 985 (55%) of whom were male and 818 (45%) female. Appendiceal perforation rate was similar between groups (77 [8%] of 907 patients assigned to the <8 h group and 81 [9%] of 896 patients assigned to the <24 h group; absolute risk difference 0·6% [95% CI -2·1 to 3·2], p=0·68; risk ratio 1·065, 95% CI 0·790 to 1·435). No significant difference was found between the complication rates within 30 days (66 [7%] of 907 patients in the <8 h group vs 56 [6%] of 896 patients in the <24 h group; difference -1·0% [-3·3 to 1·3]; p=0·39), and no deaths occurred during this follow-up period. INTERPRETATION In patients with presumed uncomplicated acute appendicitis, scheduling appendicectomy within 24 h does not increase the risk of appendiceal perforation compared with scheduling appendicectomy within 8 h. The results can be used to allocate operating room resources, for example postponing night-time appendicectomy to daytime. FUNDING The Finnish Medical Foundation, Mary and Georg Ehrnrooth's Foundation, Biomedicum Helsinki Foundation, and the Finnish Government.
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Affiliation(s)
- Karoliina Jalava
- Department of Gastroenterological Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Transplantation and Liver Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Hanna Lampela
- Department of Gastroenterological Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Hanna Malmi
- Department of Gastroenterological Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Ingeborg Steinholt
- Division of Surgery, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Gastrointestinal Surgery, Akershus University Hospital, Oslo, Norway
| | - Knut Magne Augestad
- Division of Surgery, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Gastrointestinal Surgery, Akershus University Hospital, Oslo, Norway
| | - Ari Leppäniemi
- Department of Gastroenterological Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- Department of Gastroenterological Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
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De Simone B, Kluger Y, Moore EE, Sartelli M, Abu-Zidan FM, Coccolini F, Ansaloni L, Tebala GD, Di Saverio S, Di Carlo I, Sakakushev BE, Bonavina L, Sugrue M, Galante JM, Ivatury R, Picetti E, Chirica M, Wani I, Bala M, Sall I, Kirkpatrick AW, Shelat VG, Pikoulis E, Leppäniemi A, Tan E, Broek RPGT, Gurmu Beka S, Litvin A, Chouillard E, Coimbra R, Cui Y, De' Angelis N, Sganga G, Stahel PF, Agnoletti V, Rampini A, Testini M, Bravi F, Maier RV, Biffl WL, Catena F. The new timing in acute care surgery (new TACS) classification: a WSES Delphi consensus study. World J Emerg Surg 2023; 18:32. [PMID: 37118816 PMCID: PMC10147354 DOI: 10.1186/s13017-023-00499-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/13/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Timely access to the operating room for emergency general surgery (EGS) indications remains a challenge across the globe, largely driven by operating room availability and staffing constraints. The "timing in acute care surgery" (TACS) classification was previously published to introduce a new tool to triage the timely and appropriate access of EGS patients to the operating room. However, the clinical and operational effectiveness of the TACS classification has not been investigated in subsequent validation studies. This study aimed to improve the TACS classification and provide further consensus around the appropriate use of the new TACS classification through a standardized Delphi approach with international experts. METHODS This is a validation study of the new TACS by a selected international panel of experts using the Delphi method. The TACS questionnaire was designed as a web-based survey. The consensus agreement level was established to be ≥ 75%. The collective consensus agreement was defined as the sum of the percentage of the highest Likert scale levels (4-5) out of all participants. Surgical emergency diseases and correlated clinical scenarios were defined for each of the proposed classes. Subsequent rounds were carried out until a definitive level of consensus was reached. Frequencies and percentages were calculated to determine the degree of agreement for each surgical disease. RESULTS Four polling rounds were carried out. The new TACS classification provides 6 colour-code classes correlated to a precise timing to surgery, defined scenarios and surgical condition. The WHITE colour-code class was introduced to rapidly (within a week) reschedule cancelled or postponed surgical procedures. Haemodynamic stability is the main tool to stratify patients for immediate surgery or not in the presence of sepsis/septic shock. Fifty-one surgical diseases were included in the different colour-code classes of priority. CONCLUSION The new TACS classification is a comprehensive, simple, clear and reproducible triage system which can be used to assess the severity of the patient and the surgical disease, to reduce the time to access to the operating room, and to manage the emergency surgical patients within a "safe" timeframe. By including well-defined surgical diseases in the different colour-code classes of priority, validated through a Delphi consensus, the new TACS improves communication among surgeons, between surgeons and anaesthesiologists and decreases conflicts and waste and waiting time in accessing the operating room for emergency surgical patients.
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Affiliation(s)
- Belinda De Simone
- Department of General and Emergency Surgery, Guastalla Hospital, AUSL Reggio Emilia, Guastalla, Italy.
- Unit of General and Metabolic Surgery, Clinique de St Louis, Poissy, France.
| | - Yoram Kluger
- Department of General Surgery, The Rambam Academic Hospital, Haifa, Israel
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, USA
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Federico Coccolini
- Department of General and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Luca Ansaloni
- Department of General Surgery, University Hospital of Pavia, Pavia, Italy
| | - Giovanni D Tebala
- U.O.C. Chirurgia Digestiva e d'Urgenza, Azienda Ospedaliera S.Maria, Terni, Italy
| | - Salomone Di Saverio
- Department of General Surgery, Santa Maria del Soccorso Hospital, San Benedetto del Tronto, Ascoli Piceno, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, Cannizzaro Hospital, Catania, Italy
| | - Boris E Sakakushev
- Research Institute at Medical University Plovdiv/University Hospital St George, Plovdiv, Bulgaria
| | - Luigi Bonavina
- Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Mircea Chirica
- Department of Digestive Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | | | - Miklosh Bala
- Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, Jerusalem, Israel
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Emmanouil Pikoulis
- Medical School, National and Kapodistrian University of Athens, (NKUA), Athens, Greece
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Solomon Gurmu Beka
- Department of General and Trauma Surgery, Ethiopian Air Force Hospital, Bishoftu, Ethiopia.
| | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Elie Chouillard
- Unit of General and Metabolic Surgery, Clinique de St Louis, Poissy, France
| | - Raul Coimbra
- CECORC Research Center, Riverside University Health System, Loma Linda University, Loma Linda, USA
| | - Yunfeng Cui
- Department of Surgery, Nankai Clinical School of Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | - Nicola De' Angelis
- Colorectal and Digestive Surgery Unit - DIGEST Department, Beaujon University Hospital (AP-HP), Clichy, France
| | - Gabriele Sganga
- Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Rome, Italy
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, USA
| | | | - Alessia Rampini
- Department of General and Emergency Surgery, Level I Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Mario Testini
- Department of Surgery, University Hospital of Bari, Bari, Italy
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Walter L Biffl
- Department of Emergency and Trauma Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General Surgery, Level I Trauma Center, Bufalini Hospital, Cesena, eCampus University, CREAS, Ser.In.Ar. Bologna University, Cesena, Italy
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Lepercq D, Gauss T, Godier A, Bellet J, Bouhours G, Bouzat P, Cailliau E, Cook F, David JS, Drame F, Gauthier M, Lamblin A, Pottecher J, Tavernier B, Garrigue-Huet D. Association of Organizational Pathways With the Delay of Emergency Surgery. JAMA Netw Open 2023; 6:e238145. [PMID: 37052916 PMCID: PMC10102875 DOI: 10.1001/jamanetworkopen.2023.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/24/2023] [Indexed: 04/14/2023] Open
Abstract
Importance Delayed admission of patients with surgical emergencies to the operating room occurs frequently and is associated with poor outcomes. In France, where 3 distinct organizational pathways in hospitals exist (a dedicated emergency operating room and team [DET], a dedicated operating room in a central operating theater [DOR], and no dedicated structure or team [NOR]), neither the incidence nor the influence of delayed urgent surgery is known, and no guidelines are available to date. Objective To examine the overall frequency of delayed admission of patients with surgical emergencies to the operating room across the 3 organizational pathways in hospitals in France. Design, Setting, and Participants This prospective multicenter cohort study was conducted in 10 French tertiary hospitals. All consecutive adult patients admitted for emergency surgery from October 5 to 16, 2020, were included and prospectively monitored. Patients requiring pediatric surgery, obstetrics, interventional radiology, or endoscopic procedures were excluded. Exposures Emergency surgery. Main Outcomes and Measures The main outcome was the global incidence of delayed emergency surgery across 3 predefined organizational pathways: DET, DOR, and NOR. The ratio between the actual time to surgery (observed duration between surgical indication and incision) and the ideal time to surgery (predefined optimal duration between surgical indication and incision according to the Non-Elective Surgery Triage classification) was calculated for each patient. Surgery was considered delayed when this ratio was greater than 1. Results A total of 1149 patients were included (mean [SD] age, 55 [21] years; 685 [59.9%] males): 649 in the DET group, 320 in the DOR group, and 171 in the NOR group (missing data: n = 5). The global frequency of surgical delay was 32.5% (95% CI, 29.8%-35.3%) and varied across the 3 organizational pathways: DET, 28.4% (95% CI, 24.8%-31.9%); DOR, 32.2% (95% CI, 27.0%-37.4%); and NOR, 49.1% (95% CI, 41.6%-56.7%) (P < .001). The adjusted odds ratio for delay was 1.80 (95% CI, 1.17-2.78) when comparing NOR with DET. Conclusions and Relevance In this cohort study, the frequency of delayed emergency surgery in France was 32.5%. Reduced delays were found in organizational pathways that included dedicated theaters and teams. These preliminary results may pave the way for comprehensive large-scale studies, from which results may potentially inform new guidelines for quicker and safer access to emergency surgery.
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Affiliation(s)
| | - Tobias Gauss
- Division of Anesthesia–Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Anne Godier
- Department of Anaesthesiology and Critical Care, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
- Université de Paris, Inserm, Innovations Thérapeutiques en Hémostase, Paris, France
| | - Julie Bellet
- Pôle d’anesthésie-réanimation, CHU de Lille, Lille, France
| | - Guillaume Bouhours
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Pierre Bouzat
- University of Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, Grenoble, France
| | | | - Fabrice Cook
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII School of Medicine, Creteil, France
| | - Jean-Stéphane David
- Service d’Anesthésie Réanimation, Groupe Hospitalier Sud, Hospices Civils de Lyon, Lyon, France
| | - Fatou Drame
- AP-HP, Beaujon University Hospital, DMU PARBOL, Department of Anaesthesiology and Critical Care, Clichy, France
| | - Marvin Gauthier
- Division of Anesthesia–Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Antoine Lamblin
- Anesthesiology and Critical Care Medicine Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Espace Ethique Méditerranéen, Efaculté de Médecine de Marseille, Timone University Hospital, Marseille, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Department of Anaesthesiology, Critical Care and Perioperative Medicine, Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg, ER 3072, Strasbourg, France
| | - Benoit Tavernier
- Pôle d’anesthésie-réanimation, CHU de Lille, Lille, France
- Université Lille, CHU Lille, ULR 2694–METRICS, Lille, France
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Matias T, Axel S, Hannu K, Maarit A, Ilkka K, Juha P. Adverse events are not increased by controlled delay in surgery of acute upper extremity fractures. Sci Rep 2023; 13:1888. [PMID: 36732558 PMCID: PMC9894821 DOI: 10.1038/s41598-023-28921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
Management of the operative treatment of fractures is challenged by daily variation in patient flow. For upper limb fractures there has recently been an increasing tendency to temporarily discharge the patient to wait for a daytime operation to be performed during the next few days. The objective of this study was to study the safety of controlled delay in surgery. Upper limb fractures (N = 1 944) treated in a level 2 trauma center from 2010 to 2016 were identified and included in this retrospective cohort study with 5-year follow-up. Delay in surgery, inpatient time, readmissions, ED revisits and mortality were analyzed. Depending on the nature of the injury, controlled delay to surgery was implemented. Urgency of surgery was coded as green (2 days to 2 weeks) yellow (8-48 h) or red (less than 8 h). Harms and benefits to the groups were compared. Controlled delay of surgery (median delay of 5 days 7 h) was applied in 1 074 out of 1 944 fractures. The number of revisits to the emergency department (11.1% vs. 17.9-24.1%, p < 0.001) or hospital readmissions for any reason (0.99 per 100 person years in the delayed group vs. 3.74 and 4.35 in the non-delayed groups, p < 0.001) was no higher in patients with delayed (green) compared to those with non-delayed (yellow and red) operations. Inpatient time was significantly lower in the delayed group than other groups (IRR 2.31-3.36, (p < 0.001)). The standardized mortality ratio was 0.83 (CI 0.57-1.22) in the delayed group vs. 1.49 (CI 1.17-1.90) and 1.61 (CI 1.16-2.23) in the non-delayed groups. Controlled delay in upper limb trauma surgery did not lead to increased readmissions or mortality and was associated with reduced inpatient time.
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Affiliation(s)
- Torkki Matias
- Department of Surgery, Hospital Nova of Central Finland, Wellbeing Services County of Central Finland, Jyväskylä, Finland.
| | - Somersalo Axel
- University of Helsinki, Haartmaninkatu 4, Helsinki, Finland
| | - Kautiainen Hannu
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland.,Folkhälsan Research Center, Helsinki, Finland
| | - Ax Maarit
- Tampere University Hospital, Tampere, Finland
| | | | - Paloneva Juha
- Department of Surgery, Hospital Nova of Central Finland, Wellbeing Services County of Central Finland, Jyväskylä, Finland.,University of Eastern Finland, Kuopio, Finland
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7
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Jalava K, Sallinen V, Lampela H, Malmi H, Leppäniemi A, Mentula P. Role of delay and antibiotics on PERForation rate while waiting appendicECTomy (PERFECT): a protocol for a randomized non-inferiority trial. BJS Open 2021; 5:6377141. [PMID: 34580704 PMCID: PMC8477049 DOI: 10.1093/bjsopen/zrab089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 08/16/2021] [Indexed: 11/14/2022] Open
Abstract
Background Longer duration from symptom onset is associated with increased risk of perforation in appendicitis. In previous studies, in-hospital delay to surgery has had conflicting effects on perforation rates. Although preoperative antibiotics have been shown to reduce postoperative infections, there are no data showing that administration of antibiotics while waiting for surgery has any benefits. The aims of this study are to evaluate the role of both in-hospital delay to surgery and antibiotic treatment while waiting for surgery on the rate of appendiceal perforation. Methods This prospective, open-label, randomized, controlled non-inferiority trial compares the in-hospital delay to surgery of less than 8 hours versus less than 24 hours in adult patients with predicted uncomplicated acute appendicitis. Additionally, participants are randomized either to receive or not to receive antibiotics while waiting for surgery. The primary study endpoint is the rate of perforated appendicitis discovered during appendicectomy. The aim is to randomize 1800 patients, that is estimated to give a power of 90 per cent (χ2) for the non-inferiority margin of 5 percentage points for both layers (urgency and preoperative antibiotic). Secondary endpoints include length of hospital stay, 30-day complications graded using Clavien–Dindo classification, preoperative pain, conversion rate, histopathological diagnosis and Sunshine Appendicitis Grading System classification. Discussion There are no previous randomized controlled studies for either in-hospital delay or preoperative antibiotic treatment. The trial will yield new level 1 evidence. EU Clinical Trials Register, EudraCT Number: 2019–002348-26; registration number: NCT04378868 (http://www.clinicaltrials.gov)
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Affiliation(s)
- K Jalava
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - V Sallinen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Lampela
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Malmi
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A Leppäniemi
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Mentula
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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8
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Giorgi PD, Gallazzi E, Capitani P, D’Aliberti GA, Bove F, Chiara O, Peretti G, Schirò GR. How we managed elective, urgent, and emergency orthopedic surgery during the COVID-19 pandemic: The Milan metropolitan area experience. Bone Jt Open 2020; 1:93-97. [PMID: 33225281 PMCID: PMC7677718 DOI: 10.1302/2633-1462.15.bjo-2020-0016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The COVID-19 virus is a tremendous burden for the Italian health system. The regionally-based Italian National Health System has been reorganized. Hospitals' biggest challenge was to create new intensive care unit (ICU) beds, as the existing system was insufficient to meet new demand, especially in the most affected areas. Our institution in the Milan metropolitan area of Lombardy, the epicentre of the infection, was selected as one of the three regional hub for major trauma, serving a population of more than three million people. The aims were the increase the ICU beds and the rationalization of human and structural resources available for treating COVID-19 patients. In our hub hospital, the reorganization aimed to reduce the risk of infection and to obtained resources, in terms of beds and healthcare personnel to be use in the COVID-19 emergency. Non-urgent outpatient orthopaedic activity and elective surgery was also suspended. A training programme for healthcare personnel started immediately. Orthopaedic and radiological pathways dedicated to COVID-19 patients, or with possible infection, have been established. In our orthopaedic department, we passed from 70 to 26 beds. Our goal is to treat trauma surgery's patient in the "golden 72 hours" in order to reduce the overall hospital length of stay. We applied an objective priority system to manage the flow of surgical procedures in the emergency room based on clinical outcomes and guidelines. Organizing the present to face the emergency is a challenge, but in the global plan of changes in hospital management one must also think about the near future. We reported the Milan metropolitan area orthopaedic surgery management during the COVID-19 pandemic. Our decisions are not based on scientific evidence; therefore, the decision on how reorganize hospitals will likely remain in the hands of individual countries.
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Affiliation(s)
- Pietro Domenico Giorgi
- Orthopedics and Traumatology Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Enrico Gallazzi
- Orthopedics and Traumatology Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paolo Capitani
- Orthopedics and Traumatology Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Antiono D’Aliberti
- Neurosurgery Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Federico Bove
- Orthopedics and Traumatology Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Peretti
- Department of Biomedical Sciences for Health, University of Milan, Via Riccardo Galeazzi 4, 20161, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy
| | - Giuseppe Rosario Schirò
- Orthopedics and Traumatology Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Abstract
OBJECTIVE To examine national adherence to emergency general surgery (EGS) best practices. BACKGROUND There is a national crisis in access to high-quality care for general surgery emergencies. Acute care surgery (ACS), a specialty leveraging strengths of trauma systems, may ameliorate this crisis. A critical component of trauma care is adherence to clinical guidelines. We previously established best practices for EGS using RAND Appropriateness Methodology and pilot data. METHOD A hybrid (postal/electronic) questionnaire measuring adherence to 20 EGS best practices was administered to respondents overseeing EGS at all eligible adult acute care general hospitals across the US (N = 2811). Questionnaire responses were analyzed using bivariate methods and multiple logistic regression. RESULTS The response rate was 60.1%. Adherence ranged from 8.5% for having an EGS registry to 86.2% for auditing 30-day postoperative readmissions. Adherence was higher for practices not restricted to EGS (eg, auditing readmissions) compared to EGS-specific practices (eg, registry, activation system). Adopting an ACS model of care increased adherence to practices for deferring elective cases; tiering urgent operations; following National Comprehensive Cancer Network guidelines; reversing anticoagulants; auditing returns to intensive care, time to evaluation, time to operation, and time to source control; and having transfer agreements to receive patients, ICU admission protocols, as well as EGS-specific activation systems, outpatient clinics, morbidity and mortality conferences, and registries. CONCLUSIONS There is substantial room for performance improvement, and adopting an ACS model predicts better performance. This novel overview of adherence to EGS best practices will enable surgeons and policymakers to address variations in EGS care nationally.
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Panagiotopoulou IG, Bennett JMH, Tweedle EM, Di Saverio S, Gourgiotis S, Hardwick RH, Wheeler JMD, Justin Davies R. Enhancing the emergency general surgical service: an example of the aggregation of marginal gains. Ann R Coll Surg Engl 2019; 101:479-486. [PMID: 31155901 PMCID: PMC6667960 DOI: 10.1308/rcsann.2019.0061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We aimed to enhance the emergency general surgical service in our high-volume centre in order to reduce four-hour target breaches, to expedite senior decision making and to avoid unnecessary admissions. MATERIALS AND METHODS The aggregation of marginal gains theory was applied. A dual consultant on-call system was established by the incremental employment of five emergency general surgeons with a specialist interest in colorectal or oesophagogastric surgery. A surgical ambulatory care unit, which combines consultant-led clinical review with dedicated next-day radiology slots, and a dedicated working week half-day gastrointestinal urgent theatre session were instituted to facilitate ambulatory care pathways. RESULTS The presence of two consultant surgeons being on call during weekday working hours decreased the four-hour target breaches and allowed consultant presence in the surgical ambulatory care clinic and the gastrointestinal urgent theatre list. Of 1371 surgical ambulatory care clinic appointments within 30 months, 1135 (82.7%) avoided a hospital admission, corresponding to savings of £309,752 . The coordinated functioning of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list resulted in statistically significantly reduced hospital stays for patients operated for abscess drainage (gastrointestinal urgent theatre median 11 hours (interquartile range 3, 38) compared with emergency median 31 hours (interquartile range 24, 53), P < 0.001) or diagnostic laparoscopy/appendicectomy (gastrointestinal urgent theatre median 52 hours (interquartile range 41, 71) compared with emergency median 61 hours (interquartile range 43, 99), P = 0.005). Overnight surgery was reduced with only surgery that was absolutely necessary occurring out of hours. CONCLUSION The expansion of the 'traditional' on-call surgical team, the establishment of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list led to marginal gains with a reduction in unnecessary inpatient stays, expedited decision making and improved financial efficiency.
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Affiliation(s)
- IG Panagiotopoulou
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - JMH Bennett
- Oesophagogastric Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - EM Tweedle
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Di Saverio
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Gourgiotis
- Oesophagogastric Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - RH Hardwick
- Oesophagogastric Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - JMD Wheeler
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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11
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Koivukangas V, Saarela A, Meriläinen S, Wiik H. How Well Planned Urgency Class Come True in The Emergency Surgery? Timing of Acute Care Surgery. Scand J Surg 2019; 109:85-88. [PMID: 30786828 DOI: 10.1177/1457496919826716] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Emergency surgery represents an essential aspect of surgical care, but little is known about realization of the planned emergency class. Different systems such as NCEPOD classification and Timing of Acute Care Surgery classification have been developed for the timing of the emergency surgery. The aim of the study was to find out how well planned urgency class is being implemented. MATERIALS AND METHODS The planned and realized waiting times for all emergency surgeries were studied during the 6-month period in the Oulu University Hospital. The catchment area of the hospital includes a population of 742,000. The urgency in the hospital is planned in a four-step scale: an extremely urgent (E) patient should be taken immediately to the operating theater. Class I urgency surgery should start within 3 h (180 min), class II within 8 h (480 min), and class III within 24 h (1440 min). Surgeon plans urgency at his discretion, and no specific urgency has been imposed on certain diagnoses thus the surgeon's perceptions of the illness or trauma affects the assessment. RESULTS Extreme urgent patients had an average waiting time of 26 min. For class I patient, the average waiting time was 59 min, while 93% of surgeries were started within the target time. For class II and class III patients, these figures were 337 min and 86% and 830 min and 78%, respectively. CONCLUSION With regard to urgency, the higher the degree of urgency, the greater the chance of the surgery being realized within the planned time.
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Affiliation(s)
- V Koivukangas
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - A Saarela
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - S Meriläinen
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - H Wiik
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
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12
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Ax M, Reito A, Koskimaa M, Uutela A, Paloneva J. Scheduled Emergency Trauma Operation: The Green Line Orthopedic Trauma Surgery Process Of Care. Scand J Surg 2018; 108:250-257. [PMID: 30278834 DOI: 10.1177/1457496918803015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Traditionally, patients requiring an orthopedic emergency operation were admitted to an inpatient ward to await surgery. This often led to congestion of wards and operation rooms while, for less urgent traumas, the time spent waiting for the operation often became unacceptably long. The purpose of this study was to evaluate the flow of patients coded green in a traffic light-based coding process aimed at decreasing the burden on wards and enabling a scheduled emergency operation in Central Finland Hospital. MATERIALS AND METHODS Operation urgency was divided into three categories: green (>48 h), yellow (8-48 h), and red (<8 h). Patients, who had sustained an orthopedic trauma requiring surgery, but not inpatient care (green), were assigned an operation via green line process. They were discharged until the operation, which was scheduled to take place during office hours. RESULTS Between January 2010 and April 2015, 1830 green line process operations and 5838 inpatient emergency operations were performed. The most common green line process diagnoses were distal radial fracture (15.4% of green line process), (postoperative) complications (7.7%), and finger fractures (4.9%). The most common inpatient emergency operation diagnosis was hip fracture (24.3%). Green line process and inpatient emergency operation patients differed in age, physical status, diagnoses, and surgical procedures. CONCLUSION The system was found to be a safe and effective method of implementing orthopedic trauma care. It has the potential to release operation room time for more urgent surgery, shorten the time spent in hospital, and reduce the need to operate outside normal office hours.
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Affiliation(s)
- M Ax
- 1 Central Finland Hospital, Jyväskylä, Finland
| | - A Reito
- 1 Central Finland Hospital, Jyväskylä, Finland
| | - M Koskimaa
- 1 Central Finland Hospital, Jyväskylä, Finland
| | - A Uutela
- 2 Helsinki University Hospital, Helsinki, Finland
| | - J Paloneva
- 1 Central Finland Hospital, Jyväskylä, Finland
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13
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de Burlet KJ, Desmond B, Harper SJ, Larsen PD, Dennett ER. Patients requiring an acute operation: where are the delays in the process? ANZ J Surg 2018; 88:865-869. [PMID: 29984457 DOI: 10.1111/ans.14718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/29/2018] [Accepted: 05/01/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Delays to surgery for patients requiring an acute operation are associated with increased morbidity and mortality. A recent study from our institution observed long waiting times for patients booked for an acute operation. The aim of this study was to evaluate the patient's progress from presentation to arrival in the operating theatre and to identify where delays occurred. METHODS Patients undergoing acute general surgery between July 2016 and May 2017 were studied. Data were obtained for time of presentation, imaging, theatre and booking. A time interval from presentation to booking for theatre of greater than 6 h was defined as a diagnostic delay. A time interval from booking to theatre greater than the category defined time (four-level priority system) was defined as a logistic delay. RESULTS A total of 683 patients were included. A diagnostic delay was observed in 55.1%. This occurred more frequently in patients who required imaging prior to their operation (82.5 versus 41.1%, P < 0.001). Logistic delay occurred in 31.0% of the patients, and this was most common for patients booked as a category 3 (requiring surgery within 6 h, 41.8%, P < 0.001). Patients who had a diagnostic delay were significantly more likely to have a post-operative complication compared to patients who did not (17.2 versus 10.0%, P = 0.009). CONCLUSION There are significant delays associated with patients presenting to the acute general surgery service and their transition to theatre. Addressing both the diagnostic and the logistic delays in our institution should result in a significant improvement in patient care.
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Affiliation(s)
- Kirsten J de Burlet
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Brendan Desmond
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Simon J Harper
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Peter D Larsen
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Elizabeth R Dennett
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
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14
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Caesar U, Karlsson J, Hansson E. Incidence and root causes of delays in emergency orthopaedic procedures: a single-centre experience of 36,017 consecutive cases over seven years. Patient Saf Surg 2018; 12:2. [PMID: 29344088 PMCID: PMC5763611 DOI: 10.1186/s13037-018-0149-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 01/04/2018] [Indexed: 01/24/2023] Open
Abstract
Background Emergency surgery is unplanned by definition and patients are scheduled for surgery with minimal preparation. Some patients who have sustained emergency orthopaedic trauma or other conditions must be operated on immediately or within a few hours, while others can wait until the hospital’s resources permit and/or the patients’ health status has been optimised as needed. This may affect the prioritisation procedures for both emergency and elective surgery and might result in waiting lists, not only for planned procedures but also for emergencies. Method The main purpose of this retrospective, observational, single-centre study was to evaluate and describe for the number and reasons of delays, as well as waiting times in emergency orthopaedic surgery using data derived from the hospital’s records and registers. All the emergency patients scheduled for emergency surgery whose procedures were rescheduled and delayed between 1 January 2007 and 31 December 2013 were studied. Result We found that 24% (8474) of the 36,017 patients scheduled for emergency surgeries were delayed and rescheduled at least once, some several times. Eighty per cent of these delays were due to organisational causes. Twenty-one per cent of all the delayed patients had surgery within 24 h, whilst 41% waited for more than 24 h, up to 3 days. Conclusion A large number of the clinic’s emergency orthopaedic procedures were rescheduled and delayed and the majority of the delays were related to organisational reasons. The results can be interpreted in two ways; first, organisational reasons are avoidable and the potential for improvement is great and, secondly and most importantly, the delays might negatively affect patient outcomes.
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Affiliation(s)
- Ulla Caesar
- 1Sahlgrenska Academy, Institute of Clinical Sciences, Department of Orthopaedics, University of Gothenburg Sweden, Gothenburg, Sweden.,3Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jon Karlsson
- 1Sahlgrenska Academy, Institute of Clinical Sciences, Department of Orthopaedics, University of Gothenburg Sweden, Gothenburg, Sweden.,3Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Hansson
- 2Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg Sweden, Gothenburg, Sweden.,3Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
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15
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Mathur S, Lim WW, Goo TT. Emergency general surgery and trauma: Outcomes from the first consultant-led service in Singapore. Injury 2018; 49:130-134. [PMID: 28899559 DOI: 10.1016/j.injury.2017.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/29/2017] [Accepted: 09/01/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is a significant burden on public health systems from emergency surgical and trauma (ESAT) patients. In Western countries, the response has been to separate acute and elective surgery with the creation of a new sub-specialty: acute care surgery. Dedicated acute units have shown improvements in efficiency and clinical outcomes for patients. The aim of this study was to assess the results of the first such unit in Singapore. MATERIALS AND METHODS A retrospective analysis was performed of a 12-month period of acute admissions between May 2014 and April 2015, with comparison of 6-months before and after the creation of the ESAT service. The ESAT service was a consultant led dedicated team managing all daily acute and trauma patients. Demographic, efficiency and clinical outcome key performance indicators were compared. RESULTS There were 2527 acute admissions split between the two time periods. The ESAT service (N=1279) managed soft tissue infections (257, 20%), appendicitis (199, 16%) and biliary disease (175, 14%) most commonly. The most common of the 573 procedures performed were incision and drainage (242, 42%), appendicectomy (188, 33%) and laparotomy (84, 16%). Clinical outcome during the ESAT service included reduction in overall mean length of stay (4.5d to 3.5d, P<0.01) and mortality (24/1248 (1.9%) to 11/1279 (0.9%), P=0.03). Efficiency gains in theatre booking time, ED surgical review and overall costs were also noted. CONCLUSION The creation of an ESAT service has led to improved efficiency of care with no worsening of clinical outcomes for acute general surgical and trauma patients.
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Affiliation(s)
- Sachin Mathur
- Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
| | - Woan Wui Lim
- Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
| | - Tiong Thye Goo
- Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
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16
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A Comparison of Mortality Following Emergency Laparotomy Between Populations From New York State and England. Ann Surg 2017; 266:280-286. [DOI: 10.1097/sla.0000000000001964] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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17
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Battistuzzo CR, Armstrong A, Clark J, Worley L, Sharwood L, Lin P, Rooke G, Skeers P, Nolan S, Geraghty T, Nunn A, Brown DJ, Hill S, Alexander J, Millard M, Cox SF, Rao S, Watts A, Goods L, Allison GT, Agostinello J, Cameron PA, Mosley I, Liew SM, Geddes T, Middleton J, Buchanan J, Rosenfeld JV, Bernard S, Atresh S, Patel A, Schouten R, Freeman BJ, Dunlop SA, Batchelor PE. Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery. J Neurotrauma 2016; 33:1161-9. [DOI: 10.1089/neu.2015.4207] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Camila R. Battistuzzo
- Department of Medicine (Royal Melbourne Hospital), the University of Melbourne, Melbourne, Australia
| | - Alex Armstrong
- School of Animal Biology, the University of Western Australia, Perth Australia
| | - Jillian Clark
- Center for Orthopedic and Trauma Research, the University of Adelaide, Adelaide, Australia
| | - Laura Worley
- Queensland Spinal Injuries Service, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Lisa Sharwood
- John Walsh Center for Rehabilitation Research, the University of Sydney, Sydney, Australia
| | - Peny Lin
- Orthopedic Department, Middlemore Hospital, Auckland, New Zealand
| | - Gareth Rooke
- Orthopedic Department, Christchurch Hospital, Christchurch, New Zealand
| | - Peta Skeers
- Department of Medicine (Royal Melbourne Hospital), the University of Melbourne, Melbourne, Australia
| | - Sherilyn Nolan
- School of Animal Biology, the University of Western Australia, Perth Australia
| | - Timothy Geraghty
- Queensland Spinal Injuries Service, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Andrew Nunn
- Victorian Spinal Cord Service, Austin Hospital, Melbourne, Australia
| | | | - Steven Hill
- Victorian Spinal Cord Service, Austin Hospital, Melbourne, Australia
| | - Janette Alexander
- Victorian Spinal Cord Service, Austin Hospital, Melbourne, Australia
| | - Melinda Millard
- Victorian Spinal Cord Service, Austin Hospital, Melbourne, Australia
| | - Susan F. Cox
- Neuroscience Trials Australia, the Florey Institute of Neuroscience, Melbourne, Australia
| | - Sudhakar Rao
- Trauma Service, Royal Perth Hospital, Perth, Australia
| | - Ann Watts
- Spinal Unit, Royal Perth Hospital, Perth, Australia
| | - Louise Goods
- School of Animal Biology, the University of Western Australia, Perth Australia
| | - Garry T. Allison
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia
| | - Jacqui Agostinello
- Department of Medicine (Royal Melbourne Hospital), the University of Melbourne, Melbourne, Australia
| | - Peter A. Cameron
- Emergency and Trauma Center, the Alfred Hospital, Melbourne, Australia
| | - Ian Mosley
- College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
| | - Susan M. Liew
- Department of Orthopedic Surgery, the Alfred Hospital, Melbourne, Australia
| | - Tom Geddes
- Orthopedic Department, Middlemore Hospital, Auckland, New Zealand
| | - James Middleton
- John Walsh Center for Rehabilitation Research, the University of Sydney, Sydney, Australia
| | - John Buchanan
- Department of Physiotherapy, Royal Perth Hospital, Perth, Australia
| | | | - Stephen Bernard
- Intensive Care Unit, the Alfred Hospital, Melbourne, Australia
| | - Sridhar Atresh
- Queensland Spinal Injuries Service, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Alpesh Patel
- Orthopedic Department, Middlemore Hospital, Auckland, New Zealand
| | - Rowan Schouten
- Orthopedic Department, Christchurch Hospital, Christchurch, New Zealand
| | - Brian J.C. Freeman
- Department of Orthopedics and Trauma, the University of Adelaide, Adelaide, Australia
| | - Sarah A. Dunlop
- School of Animal Biology, the University of Western Australia, Perth Australia
| | - Peter E. Batchelor
- Department of Medicine (Royal Melbourne Hospital), the University of Melbourne, Melbourne, Australia
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18
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Seternes A, Fasting S, Klepstad P, Mo S, Dahl T, Björck M, Wibe A. Bedside dressing changes for open abdomen in the intensive care unit is safe and time and staff efficient. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:164. [PMID: 27233244 PMCID: PMC4884359 DOI: 10.1186/s13054-016-1337-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 05/12/2016] [Indexed: 02/03/2023]
Abstract
Background Patients with an open abdomen (OA) treated with temporary abdominal closure (TAC) need multiple surgical procedures throughout the hospital stay with repeated changes of the vacuum-assisted closure device (VAC changes). The aim of this study was to examine if using the intensive care unit (ICU) for dressing changes in OA patients was safe regarding bloodstream infections (BSI) and survival. Secondary aims were to evaluate saved time, personnel, and costs. Methods All patients treated with OA in the ICU from October 2006 to June 2014 were included. Data were retrospectively obtained from registered procedure codes, clinical and administrative patients’ records and the OR, ICU, anesthesia and microbiology databases. Outcomes were 30-, 60- and 90-day survival, BSI, time used and saved personnel costs. Results A total of 113 patients underwent 960 surgical procedures including 443 VAC changes as a single procedure, of which 165 (37 %) were performed in the ICU. Nine patients died before the first scheduled dressing change and six patients were closed at the first scheduled surgery after established OA, leaving 98 patients for further analysis. The mean duration for the surgical team performing a VAC change in the ICU was 63.4 (60.4–66.4) minutes and in the OR 98.2 (94.6–101.8) minutes (p < 0.001). The mean duration for the anesthesia team in the OR was 115.5 minutes, while this team was not used in the ICU. Personnel costs were reduced by €682 per procedure when using the ICU. Forty-two patients had all the VAC changes done in the OR (VAC-OR), 22 in the ICU (VAC-ICU) and 34 in both OR and ICU (VAC-OR/ICU). BSI was diagnosed in eight (19 %) of the VAC-OR patients, seven (32 %) of the VAC-ICU and eight (24 %) of the VAC-OR/ICU (p = 0.509). Thirty-five patients (83 %) survived 30 days in the VAC-OR group, 17 in the VAC-ICU group (77 %) and 28 (82 %) in the VAC-OR/ICU group (p = 0.844). Conclusions VAC change for OA in the ICU saved time for the OR team and the anesthesia team compared to using the OR, and it reduced personnel costs. Importantly, the use of ICU for OA dressing change seemed to be as safe as using the OR.
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Affiliation(s)
- Arne Seternes
- Department of Vascular Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway. .,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway. .,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway.
| | - Sigurd Fasting
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
| | - Skule Mo
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway
| | - Torbjørn Dahl
- Department of Vascular Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
| | - Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Arne Wibe
- Department of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway.,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
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Kim M, Kim JH, Kim SJ, Cho HJ. Ideal Time to Surgery for Acute Abdomen. JOURNAL OF ACUTE CARE SURGERY 2016. [DOI: 10.17479/jacs.2016.6.1.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Maru Kim
- Division of Trauma Surgery, Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Hoon Kim
- Division of Trauma Surgery, Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Jeep Kim
- Division of Trauma Surgery, Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hang Joo Cho
- Division of Trauma Surgery, Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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20
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21
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Søreide K. Emergency surgery over 111 years: are we still at a crossroads or ready for emergency surgery 2.0? Scand J Trauma Resusc Emerg Med 2015; 23:107. [PMID: 26689822 PMCID: PMC4687313 DOI: 10.1186/s13049-015-0189-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/09/2015] [Indexed: 01/28/2023] Open
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, N-4068, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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22
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23
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Mueller RN, Dexter F, Truong VA, Wachtel RE. Case Sequencing of Diagnostic Imaging Studies Performed Under General Anesthesia or Monitored Anesthesia Care During Nights and Weekends. ACTA ACUST UNITED AC 2015; 5:162-6. [DOI: 10.1213/xaa.0000000000000161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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24
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Shakerian R, Thomson BN, Gorelik A, Hayes IP, Skandarajah AR. Outcomes in emergency general surgery following the introduction of a consultant-led unit. Br J Surg 2015; 102:1726-32. [PMID: 26492418 DOI: 10.1002/bjs.9954] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/05/2015] [Accepted: 08/27/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients presenting with emergency surgical conditions place significant demands on healthcare services globally. The need to improve emergency surgical care has led to establishment of consultant-led emergency surgery units. The aim of this study was to determine the effect of a changed model of service on outcomes. METHODS A retrospective observational study of all consecutive emergency general surgical admissions in 2009-2012 was performed. A 2-year time frame before and after the establishment of the emergency general surgery (EGS) service was used to determine the number of admissions and operations, emergency department and hospital length of stay, as well as complication rates. RESULTS The study included 7233 acute admissions. The EGS service managed 4468 patients (61·6 per cent increase) and performed 1804 operations (41·0 per cent increase). The most common diagnoses during the EGS period included acute appendicitis (532, 11·9 per cent), biliary disease (361, 8·1 per cent) and abdominal pain (561, 12·6 per cent). Appendicectomy (536, 29·7 per cent), cholecystectomy (239, 13·2 per cent) and laparotomy (226, 12·5 per cent) were the most commonly performed procedures. In the EGS period, time in the emergency department was reduced (from 8·0 to 6·0 h; P < 0·001), as was length of hospital stay (from 3·0 to 2·0 days; P < 0·001). The number of complications was reduced by 46·8 per cent, from 172 (6·2 per cent) to 147 (3·3 per cent) (P < 0·001), with a 53 per cent reduction in the number of deaths in the EGS period, from 29 (16·9 per cent) to seven (8 per cent) (P = 0·039). CONCLUSION The establishment of a consultant-led emergency surgical service has been associated with improved provision of care, resulting in timely management and improved clinical outcomes.
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Affiliation(s)
- R Shakerian
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - B N Thomson
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - A Gorelik
- Melbourne EpiCentre, Centre for Clinical Epidemiology, Biostatistics and Health Services Research, (University of Melbourne and Melbourne Health), The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - I P Hayes
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - A R Skandarajah
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
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25
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Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015; 386:1278-1287. [PMID: 26460662 DOI: 10.1016/s0140-6736(15)00275-5] [Citation(s) in RCA: 582] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute appendicitis is one of the most common abdominal emergencies worldwide. The cause remains poorly understood, with few advances in the past few decades. To obtain a confident preoperative diagnosis is still a challenge, since the possibility of appendicitis must be entertained in any patient presenting with an acute abdomen. Although biomarkers and imaging are valuable adjuncts to history and examination, their limitations mean that clinical assessment is still the mainstay of diagnosis. A clinical classification is used to stratify management based on simple (non-perforated) and complex (gangrenous or perforated) inflammation, although many patients remain with an equivocal diagnosis, which is one of the most challenging dilemmas. An observed divide in disease course suggests that some cases of simple appendicitis might be self-limiting or respond to antibiotics alone, whereas another type often seems to perforate before the patient reaches hospital. Although the mortality rate is low, postoperative complications are common in complex disease. We discuss existing knowledge in pathogenesis, modern diagnosis, and evolving strategies in management that are leading to stratified care for patients.
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Affiliation(s)
- Aneel Bhangu
- Academic Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham UK; College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Salomone Di Saverio
- Emergency and General Surgery Department, CA Pizzardi Maggiore Hospital, Bologna, Italy
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26
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Scott AJ, Mason SE, Arunakirinathan M, Reissis Y, Kinross JM, Smith JJ. Risk stratification by the Appendicitis Inflammatory Response score to guide decision-making in patients with suspected appendicitis. Br J Surg 2015; 102:563-72. [PMID: 25727811 DOI: 10.1002/bjs.9773] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/28/2014] [Accepted: 12/12/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Current management of suspected appendicitis is hampered by the overadmission of patients with non-specific abdominal pain and a significant negative exploration rate. The potential benefits of risk stratification by the Appendicitis Inflammatory Response (AIR) score to guide clinical decision-making were assessed. METHODS During this 50-week prospective observational study at one institution, the AIR score was calculated for all patients admitted with suspected appendicitis. Appendicitis was diagnosed by histological examination, and patients were classified as having non-appendicitis pain if histological findings were negative or surgery was not performed. The diagnostic performance of the AIR score and the potential for risk stratification to reduce admissions, optimize imaging and prevent unnecessary explorations were quantified. RESULTS A total of 464 patients were included, of whom 210 (63·3 per cent) with non-appendicitis pain were correctly classified as low risk. However, 13 low-risk patients had appendicitis. Low-risk patients accounted for 48·1 per cent of admissions (223 of 464), 57 per cent of negative explorations (48 of 84) and 50·7 per cent of imaging requests (149 of 294). An AIR score of 5 or more (intermediate and high risk) had high sensitivity for all severities of appendicitis (90 per cent) and also for advanced appendicitis (98 per cent). An AIR score of 9 or more (high risk) was very specific (97 per cent) for appendicitis, and the majority of patients with appendicitis in the high-risk group (21 of 30, 70 per cent) had perforation or gangrene. Ultrasound imaging could not exclude appendicitis in low-risk patients (negative likelihood ratio (LR) 1·0) but could rule-in the diagnosis in intermediate-risk patients (positive LR 10·2). CT could exclude appendicitis in low-risk patients (negative LR 0·0) and rule-in appendicitis in the intermediate group (positive LR 10·9). CONCLUSION Risk stratification of patients with suspected appendicitis by the AIR score could guide decision-making to reduce admissions, optimize utility of diagnostic imaging and prevent negative explorations.
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Affiliation(s)
- A J Scott
- Academic Surgical Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
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Søreide K, Desserud KF. Emergency surgery in the elderly: the balance between function, frailty, fatality and futility. Scand J Trauma Resusc Emerg Med 2015; 23:10. [PMID: 25645443 PMCID: PMC4320594 DOI: 10.1186/s13049-015-0099-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/21/2015] [Indexed: 12/15/2022] Open
Abstract
Becoming old is considered a privilege and results from the socioeconomic progress and improvements in health care systems worldwide. However, morbidity and mortality increases with age, and even more so in acute onset disease. With the current prospects of longevity, a considerable number of elderly patients will continue to live with good function and excellent quality of life after emergency surgical care. However, mortality in emergency surgery may be reported at 15-30%, doubled if associated with complications, and notably higher in patients over 75 years. A number of risks associated with death are reported, and a number of scores proposed for prediction of risk. Frailty, a decline in the physiological reserves that may make the person vulnerable to even the most minor of stressful event, appears to be a valid indicator and predictor of risk and poor outcome, but how to best address and measure frailty in the emergency setting is not clear. Futility may sometimes be clearly defined, but most often becomes a borderline decision between ethics, clinical predictions and patient communication for which no solid evidence currently exists. The number and severity of other underlying condition(s), as well as the treatment alternatives and their consequences, is a complex picture to interpret. Add in the onset of the acute surgical disease as a further potential detrimental factor on function and quality of life – and you have a perfect storm to handle. In this brief review, some of the challenging aspects related to emergency surgery in the elderly will be discussed. More research, including registries and trials, are needed for improved knowledge to a growing health care challenge.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kari F Desserud
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
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Beecher S, O'Leary DP, McLaughlin R. Hospital tests and patient related factors influencing time-to-theatre in 1000 cases of suspected appendicitis: a cohort study. World J Emerg Surg 2015; 10:6. [PMID: 25685177 PMCID: PMC4328835 DOI: 10.1186/1749-7922-10-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 01/18/2015] [Indexed: 01/26/2023] Open
Abstract
Background Acute appendicitis is increasingly being managed in the setting of a dedicated emergency theatre. However understanding of hospital factors that influence time-to-theatre (TTT) is poor. Thus, the aim of this study is to identify factors that influence TTT and to observe the effect of prolonged TTT on patient outcome. Methods A retrospective review of an electronic prospectively maintained database was performed over a 2 year period. Factors thought to influence TTT were highlighted. A delay was defined as TTT >8 hours. Data analysis was performed using SPSS 20. Results 1,000 cases of suspected acute appendicitis were identified. Median age was 19 years. Appendicectomy was performed in 90.7%. 68.1% underwent laparoscopic appendicectomy. Overall mean TTT was 12 hours, 27 minutes. There was a significant association between delayed TTT and female gender (p = 0.017), older age (p = 0.001), pre-operative radiology (<0.001), normal WCC (p < 0.001), normal neutrophils (p < 0.001) and histological non-perforated appendix (p < 0.001). However, on multivariate analysis, younger age, a neutrophilia and presence of a perforation had a shorter TTT. Delayed TTT did not affect outcome variables including post-operative collection (3.59% v 4.38%, p = 0.528), readmission rate (6.54% v 5.72%, p = 0.403) and length of stay (3.1 days v 3.34 days, p = 0.823). Conclusions This study highlights key hospital factors that influence TTT in patients with suspected appendicitis. Identification of these influential factors adds greatly to our understanding of patient prioritisation. Finally, TTT delays greater than 8 hour do not appear to affect short-term patient outcomes.
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Affiliation(s)
- Suzanne Beecher
- Department of Surgery, Galway University Hospital/National University of Ireland (NUI), Galway, Republic of Ireland
| | - Donal Peter O'Leary
- Department of Surgery, Galway University Hospital/National University of Ireland (NUI), Galway, Republic of Ireland
| | - Ray McLaughlin
- Department of Surgery, Galway University Hospital/National University of Ireland (NUI), Galway, Republic of Ireland
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