1
|
Pule LM, Kopunic H, Aitken RJ. Low mortality rate after emergency laparotomy in Australia is a reflection of its national surgical mortality audit influencing futile surgery. Br J Surg 2023; 110:1367-1373. [PMID: 37409943 DOI: 10.1093/bjs/znad200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/06/2023] [Accepted: 06/13/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Australia's unique national surgical mortality audit has had a long-term focus on the avoidance of futile surgery. The 30-day mortality rate after emergency laparotomy in Australia is lower than in other countries. Early death (within 72 h) after emergency laparotomy may reflect futile surgery. This paper considers whether Australia's national mortality audit is the reason for its lower mortality rate after emergency laparotomy. METHODS Data were extracted from the Australia and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) from 2018 to 2022. The time elapsed from emergency laparotomy to death was determined for each patient. The cumulative daily mortality rate was calculated for the first 30 days and expressed as a proportion of all emergency laparotomies, and 30-day and in-hospital mortality. Mortality data were compared with those in the only three similar overseas studies. The mortality rate after emergency laparotomy for patients who required but did not undergo surgery was calculated for each hospital. The proportion of patients with high-risk characteristics was compared with that in the National Emergency Laparotomy Audit (NELA). RESULTS Compared with overseas studies, there was a lower early (within 72 h) mortality rate in ANZELA-QI. Although the lower mortality rate in ANZELA-QI persisted to 30 days, there was a relative increase after 14 days that likely reflected known poor compliance with care standards. Australian patients had fewer high-risk characteristics than those in NELA. CONCLUSION The present findings support the hypothesis that the lower mortality rate after emergency laparotomy in Australia is likely a consequence of its national mortality audit and the avoidance of futile surgery.
Collapse
Affiliation(s)
- Lettie M Pule
- Royal Australasian College of Surgeons, Morbidity Audits, Research, Audit & Academic Surgery, Adelaide, South Australia, Australia
| | - Helena Kopunic
- Royal Australasian College of Surgeons, Morbidity Audits, Research, Audit & Academic Surgery, Adelaide, South Australia, Australia
| | - R James Aitken
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| |
Collapse
|
2
|
Faleiro MD, Fernandez MG, Santos JM, Menezes CEG, Lima JVS, Haddad JOD, Viana SW, Alonso N. Geographical Inequalities in Access to Bellwether Procedures in Brazil. World J Surg 2023; 47:593-599. [PMID: 36456731 PMCID: PMC9714764 DOI: 10.1007/s00268-022-06855-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Brazil is a middle-income country that aims to provide universal health coverage, but its surgical system's efficiency has rarely been analyzed. In an effort to strengthen surgical national systems, the Lancet Commission on Global Surgery proposed bellwether procedures as quality indicators of surgical workforces. This study aims to evaluate regional inequalities in access to bellwether procedures and their associated mortality across the five Brazilian geographical regions. METHODS Using DATASUS, Brazil's national healthcare database, data were collected on the total amount of performed bellwether procedures-cesarean section, laparotomy, and open fracture management-and their associated mortality, by geographical region. We evaluated the years 2018-2020, both in emergent and elective conditions. Statistical analysis was performed by one-way ANOVA test and Tukey's multiple comparisons test. RESULTS During this period, DATASUS registered 2,687,179 cesarean sections, 1,036,841 laparotomies, and 648,961 open fracture treatments. The access and associated mortality related to these procedures were homogeneous between the regions in elective care. There were significant geographical inequalities in access and associated mortality in emergency care (p < 0.05, 95% CI) for all bellwether procedures. The Southeast, the most economically developed region of the country, was the region with the lowest amount of bellwether procedures per 100,000 inhabitants. CONCLUSION Brazil's public surgical system is competent at promoting elective surgical care, but more effort is needed to fortify emergency care services. Public policies should encourage equity in the geographic allocation of the surgical workforce.
Collapse
Affiliation(s)
- Matheus Daniel Faleiro
- Federal University of Minas Gerais, Belo Horizonte, Brazil.
- International Student Surgical Network Brazil, Belo Horizonte, Brazil.
| | - Miguel Godeiro Fernandez
- International Student Surgical Network Brazil, Belo Horizonte, Brazil
- Bahiana School of Medicine and Public Health (EBMSP), Salvador, Brazil
| | - Jéssica Moreira Santos
- International Student Surgical Network Brazil, Belo Horizonte, Brazil
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil
| | - Catarina Ester Gomes Menezes
- International Student Surgical Network Brazil, Belo Horizonte, Brazil
- State University of Bahia, Salvador, Brazil
| | - João Vitor Sabadine Lima
- Federal University of Minas Gerais, Belo Horizonte, Brazil
- International Student Surgical Network Brazil, Belo Horizonte, Brazil
| | | | - Sofia Wagemaker Viana
- International Student Surgical Network Brazil, Belo Horizonte, Brazil
- Kursk State Medical University, Kursk, Russia
| | - Nivaldo Alonso
- Division of Plastic Surgery, University of São Paulo, São Paulo, Brazil
| |
Collapse
|
3
|
Nally DM, Lonergan PE, O’Connell EP, McNamara DA, Elwahab SA, Bass G, Burke E, Cagney D, Canas A, Cronin C, Cullinane C, Devane L, Fearon N, Fowler A, Fullard A, Hechtl D, Kelly M, Lenihan J, Murphy E, Neary C, O'Connell R, O'Neill M, Ramkaran C, Troy A, Tully R, White C, Yadav H. Increasing the use of perioperative risk scoring in emergency laparotomy: nationwide quality improvement programme. BJS Open 2022; 6:6649489. [PMID: 35876188 PMCID: PMC9309802 DOI: 10.1093/bjsopen/zrac092] [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: 09/03/2021] [Revised: 06/07/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Emergency laparotomy is associated with high morbidity and mortality. The early identification of high-risk patients allows for timely perioperative care and appropriate resource allocation. The aim of this study was to develop a nationwide surgical trainee-led quality improvement (QI) programme to increase the use of perioperative risk scoring in emergency laparotomy. Methods The programme was structured using the active implementation framework in 15 state-funded Irish hospitals to guide the staged implementation of perioperative risk scoring. The primary outcome was a recorded preoperative risk score for patients undergoing an emergency laparotomy at each site. Results The rate of patients undergoing emergency laparotomy receiving a perioperative risk score increased from 0–11 per cent during the exploratory phase to 35–100 per cent during the full implementation phase. Crucial factors for implementing changes included an experienced central team providing implementation support, collaborator engagement, and effective communication and social relationships. Conclusions A trainee-led QI programme increased the use of perioperative risk assessment in patients undergoing emergency laparotomy, with the potential to improve patient outcomes and care delivery.
Collapse
Affiliation(s)
- Deirdre M Nally
- Department of Surgical Affairs, Royal College of Surgeons in Ireland , Dublin , Ireland
- Department of Surgery, Mater Misericordiae University Hospital , Dublin , Ireland
| | - Peter E Lonergan
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland , Dublin , Ireland
- Department of Urology, St. James’s Hospital , Dublin , Ireland
- Department of Surgery, Trinity College , Dublin , Ireland
| | | | - Deborah A McNamara
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland , Dublin , Ireland
- Department of Surgery, Beaumont Hospital , Dublin , Ireland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Song J, Cheng C, Sheng K, Jiang LL, Li Y, Xia XQ, Hu XW. Association between the reactivity of local cerebral oxygen saturation after hypo-to-hypercapnic tests and delirium after abdominal surgery in older adults: A prospective study. Front Psychiatry 2022; 13:907870. [PMID: 36405895 PMCID: PMC9672925 DOI: 10.3389/fpsyt.2022.907870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the correlation between changes in regional cerebral oxygen saturation (rSO2) and postoperative delirium in older adults undergoing major abdominal surgery. MATERIALS AND METHODS This prospective study enrolled older adults scheduled for elective major abdominal surgery at the Second Affiliated Hospital of Anhui Medical University from August 2021 to January 2022. The change in rSO2 from baseline was determined using the hypo-to-hypercapnic test. The main study outcome was the occurrence of postoperative delirium. RESULTS A total of 101 participants were included for analysis, of whom 16 (15.8%) developed postoperative delirium. Compared with non-delirium participants, the mean arterial pressure and heart rate were not significantly different in the postoperative delirium group at T0, T1, T2, T3, T4, and T6 (all Pinteraction > 0.05), but the delirium group had lower pH, lower PaO2, and higher lactate levels at T4, T5, and T6 (all Pinteraction < 0.05). rSO2 at T0, T1, T2, T3, T4, and T6 was 69.0 (63.2-75.2), 70.7 ± 7.3, 68.2 ± 7.5, 72.1 ± 8.0, 69.9 ± 7.8, 67.4 ± 7.2, and 71.7 ± 8.1, respectively. The postoperative change in rSO2 during the hypercapnia test (TΔrSO2%) was 6.62 (5.31-9.36). Multivariable analysis showed that the Cumulative Illness Rating Scale (odd ratio, OR = 1.89, 95% confidence interval, CI: 1.10-3.25, P = 0.021), preoperative albumin levels (OR = 0.67, 95% CI: 0.48-0.94, P = 0.022), rSO2 at T4 (OR = 0.61, 95% CI: 0.41-0.89, P = 0.010), and postoperative TΔrSO2% (OR = 0.80, 95% CI: 0.66-0.98, P = 0.028) were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery. CONCLUSION The rSO2 measured at T4 and postoperative TΔrSO2% were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery.
Collapse
Affiliation(s)
- Jie Song
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chen Cheng
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Kui Sheng
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ling-Ling Jiang
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yun Li
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xiao-Qiong Xia
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China.,Department of Anaesthesiology, The Chaohu Affliated Hospital of Anhui Medical University, Hefei, China
| | - Xian-Wen Hu
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| |
Collapse
|
5
|
Law J, Welch C, Javanmard-Emamghissi H, Clark M, Bisset CN, O'Neil P, Moug SJ. Decision-making for older patients undergoing emergency laparotomy: defining patient and clinician values and priorities. Colorectal Dis 2020; 22:1694-1703. [PMID: 32464712 DOI: 10.1111/codi.15165] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/07/2020] [Indexed: 01/05/2023]
Abstract
AIM There remains limited knowledge on what patients value and prioritize in their decision to undergo emergency laparotomy (ELap) and during their subsequent recovery. The aim of this study was to explore factors in decision-making and to reach a consensus amongst patients on the 10 most important priorities in decision-making in ELap. METHODS Patients aged over 65 years who had required an ELap decision within the preceding 12 months (regardless of management) were identified and invited to attend a modified Delphi process focus group. RESULTS A total of 20 participants attended: eight patients, four relatives and eight perioperative specialists. The perioperative specialists group defined 12 important factors for perioperative decision-making. The patient group agreed that only six (50%) of these factors were important: independence, postoperative complications, readmission to hospital, requirement for stoma formation, delirium (including long-term cognition) and presence of an advocate (such as a friend or family member). Open discussion refined multiple themes. Agreement was reached by patients and relatives about 10 factors that they valued as most important in their ELap patient journey: return to independence, realistic expectations, postoperative complications, what to expect postoperatively, readmission to hospital, nutrition, postoperative communication, stoma, follow-up and delirium. CONCLUSION Patients and clinicians have different values and priorities when discussing the risks and implications of undergoing ELap. Patients value quality of life outcomes, in particular, the formation of a stoma, returning to their own home and remaining independent. This work is the first to combine both perspectives to guide future ELap research outcomes.
Collapse
Affiliation(s)
- J Law
- Blackpool Victoria Hospital, North West Deanery, UK
| | - C Welch
- Geriatric Medicine, University of Birmingham,, Birmingham, UK
| | | | - M Clark
- Royal Alexandra Hospital, Paisley, UK
| | | | - P O'Neil
- Royal Alexandra Hospital, Paisley, UK
| | - S J Moug
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK
| | | |
Collapse
|
6
|
McCann A, Sorensen J, Nally D, Kavanagh D, McNamara DA. Discharge outcomes among elderly patients undergoing emergency abdominal surgery: registry study of discharge data from Irish public hospitals. BMC Geriatr 2020; 20:72. [PMID: 32075577 PMCID: PMC7031938 DOI: 10.1186/s12877-020-1469-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intra-abdominal emergency surgery is associated with high mortality risk and long length of hospital stay. The objective of this study was to explore variations in surgery rates, the relationship between admission source and discharge destination, and whether the postoperative length of stay was related to nursing home capacity in Irish counties. METHODS Data on emergency hospital episodes for 2014-18 for patients aged over 65 years with a primary abdominal procedure code were obtained from the National Quality Assurance Improvement System. Data on population and nursing home capacity were obtained from the Central Statistics Office and the Health Information and Quality Authority. Episode rates per 100,000 were estimated for sex and age groups and compared between 26 Irish counties. The association between admission source and discharge destination was explored in terms episode numbers, length of stay and mortality. A negative binomial regression model estimated casemix adjusted excess post-operative length of stay. The correlation between excess post-operative length of stay and nursing home capacity was explored by linear regression. RESULTS Overall, 4951 hospital episodes were included. The annual surgery rate ranged from 100 episodes per 100,000 65-69 years old to 250 per 100,000 85-89 year old men. 90% of the episodes were admitted from patients' home. Four in five of these patients returned to their home while 12.7% died at hospital. The proportion of episodes where patients returned to their home reduced to two in five for those aged 85-89 years. The post-operative length of stay was 13.6 days longer (p < 0.01) for episodes admitted from home and discharged to nursing home in comparison with episodes discharged home. A negative association (p = 0.08) was found between excess post-operative length of stay and county-level nursing home capacity. CONCLUSIONS This study provides relevant information to support informed consent to surgery for patients and clinicians and to improve the provision of care to older patients presenting with intra-abdominal emergencies.
Collapse
Affiliation(s)
- Aisling McCann
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland, 2 Proud’s Lane, Dublin, Ireland
| | - Jan Sorensen
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland, Beaux Lane House, Mercer Street Lower, Dublin, Ireland
| | - Deirdre Nally
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, 121 St. Stephen’s Green, Dublin, Ireland
| | - Dara Kavanagh
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, 121 St. Stephen’s Green, Dublin, Ireland
| | - Deborah A. McNamara
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland, 2 Proud’s Lane, Dublin, Ireland
| |
Collapse
|