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Chen L, Tu QM, Guo ZD, Zhu XW, Wang W, Xie HF, Ye Y. Effect analysis of applying high-quality service model to surgical nursing. World J Clin Cases 2024; 12:3744-3751. [PMID: 38994287 PMCID: PMC11235455 DOI: 10.12998/wjcc.v12.i19.3744] [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: 03/09/2024] [Revised: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Surgical care of the hand plays a crucial role in the medical field, as problems with the hand can profoundly affect a patient's quality of life and function. In order to meet the needs of patients, improve patient satisfaction and improve treatment outcomes, high-quality service models have been introduced in the field of nursing. AIM To explore the effect analysis of applying high-quality service model to surgical nursing. METHODS We conducted a retrospective study of patients who underwent hand surgery at our hospital between 2019 and 2022, using a quality service model that included improved patient education, pain management, care team collaboration, and effective communication. Another group of patients received traditional care as a control group. We compared postoperative recovery, satisfaction, complication rate, and length of hospital stay between the two groups. Inferential statistics were used to compare the difference between the two groups by independent sample t test, Chi-square test and other methods to evaluate the effect of intervention measures. RESULTS Postoperative recovery time decreased from 17.8 ± 2.3 d to 14.5 ± 2.1 d, pain score decreased from 4.7 ± 1.9 to 3.2 ± 1.4, and hand function score increased from 78.4 ± 7.1 to 88.5 ± 6.2. In terms of patient satisfaction, the quality service model group scored 87.3 ± 5.6 points, which was significantly higher than that of the traditional care group (74.6 ± 6.3 points). At the same time, patients' understanding of medical information also improved from 6.9 ± 1.4 to 8.6 ± 1.2. In terms of postoperative complications, the application of the quality service model reduced the incidence of postoperative complications from 26% to 10%, the incidence of infection from 12% to 5%, and the incidence of bleeding from 10% to 3%. The reduction in these data indicates that the quality service model plays a positive role in reducing the risk of complications. In addition, the average hospital stay of patients in the quality service model group was shortened from 6.8 ± 1.5 d to 5.2 ± 1.3 d, and the hospitalization cost was also reduced from 2800 ± 600 yuan to 2500 ± 500 yuan. CONCLUSION Applying a quality service model to hand surgery care can significantly improve patient clinical outcomes, including faster recovery, less pain, greater satisfaction, and reduced complication rates.
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Affiliation(s)
- Li Chen
- Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan 430200, Hubei Province, China
| | - Qiu-Mei Tu
- Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan 430200, Hubei Province, China
| | - Zhao-Di Guo
- Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan 430200, Hubei Province, China
| | - Xiao-Wei Zhu
- Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan 430200, Hubei Province, China
| | - Wei Wang
- Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan 430200, Hubei Province, China
| | - Hui-Fang Xie
- Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan 430200, Hubei Province, China
| | - Yuan Ye
- Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan 430200, Hubei Province, China
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Nicolás-Pérez D, Gimeno-García AZ, Romero-García RJ, Castilla-Rodríguez I, Hernandez-Guerra M. Cost-effectiveness Analysis of Single-Use Duodenoscope Applied to Endoscopic Retrograde Cholangiopancreatography. Pancreas 2024; 53:e357-e367. [PMID: 38518062 DOI: 10.1097/mpa.0000000000002311] [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] [Indexed: 03/24/2024]
Abstract
OBJECTIVES Secondary infections due to transmission via the duodenoscope have been reported in up to 3% of endoscopic retrograde cholangiopancreatographies. The use of single-use duodenoscopes has been suggested. We investigate the cost-effectiveness of these duodenoscopes use in cholangiopancreatography. MATERIALS AND METHODS A cost-effectiveness analysis was implemented to compare the performance of cholangiopancreatographies with reusable duodenoscopes versus single-use duodenoscopes. Effectiveness was analyzed by calculating quality-adjusted life years (QALY) from the perspective of the National Health System. Possibility of crossover from single-use to reusable duodenoscopes was considered. A willingness-to-pay of €25,000/QALY was set, the incremental cost-effectiveness ratio (ICER) was calculated, and deterministic and probabilistic sensitivity analyses were performed. RESULTS Considering cholangiopancreatographies with single-use and reusable duodenoscopes at a cost of €2900 and €1333, respectively, and a 10% rate of single-use duodenoscopes, ICER was greater than €3,000,000/QALY. A lower single-use duodenoscope cost of €1211 resulted in an ICER of €23,583/QALY. When the unit cost of the single-use duodenoscope was €1211, a crossover rate of more than 9.5% made the use of the single-use duodenoscope inefficient. CONCLUSIONS Single-use duodenoscopes are cost-effective in a proportion of cholangiopancreatographies if its cost is reduced. Increased crossover rate makes single-use duodenoscope use not cost-effective.
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Affiliation(s)
| | | | | | - Iván Castilla-Rodríguez
- Departamento de Ingeniería Informática y de Sistemas, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
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Bergeron E, Doyon T, Manière T, Désilets É. Cholecystectomy following endoscopic clearance of common bile duct during the same admission. Can J Surg 2023; 66:E477-E484. [PMID: 37734850 PMCID: PMC10521812 DOI: 10.1503/cjs.008322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND The recurrence of common bile duct stones and other biliary events after endoscopic retrograde cholangiopancreatography (ERCP) is frequent. Despite recommendations for early cholecystectomy, intervention during the same admission is carried out inconsistently. METHODS We reviewed the records of patients who underwent ERCP for gallstone disease and common bile duct clearance followed by cholecystectomy between July 2012 and June 2022. Patients were divided into 2 groups: the index group underwent cholecystectomy during the same admission and the delayed group was discharged and had their cholecystectomy postponed. Data on demographics and prognosis factors were collected and analyzed. RESULTS The study population was composed of 268 patients, with 71 (26.6%) having undergone cholecystectomy during the same admission after common bile duct clearance with ERCP. A greater proportion of patients aged 80 years and older were in the index group than in the delayed group. The American Society of Anesthesiologists score was significantly higher in the index group. There was no significant difference between groups regarding surgical complications, open cholecystectomy and death. The operative time was significantly longer in the delayed group. Among patients with delayed cholecystectomy, 18.3% had at least 1 recurrence of common bile duct stones (CBDS) and 38.6% had recurrence of any gallstone-related events before cholecystectomy. None of these events occurred in the the index group. There was no difference in the recurrence of CBDS and other biliary events after initial diagnosis associated with stone disease. CONCLUSION Cholecystectomy during the same admission after common bile duct clearance is safe, even in older adults with comorbidities. Compared with delayed cholecystectomy, it was not associated with adverse outcomes and may have prevented recurrence of biliary events.
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Affiliation(s)
- Eric Bergeron
- Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, Que. (Bergeron); Department of Gastroenterology, Hôpital Charles LeMoyne, Greenfield Park, Que. (Doyon, Maniere, Desilets)
| | - Théo Doyon
- Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, Que. (Bergeron); Department of Gastroenterology, Hôpital Charles LeMoyne, Greenfield Park, Que. (Doyon, Maniere, Desilets)
| | - Thibaut Manière
- Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, Que. (Bergeron); Department of Gastroenterology, Hôpital Charles LeMoyne, Greenfield Park, Que. (Doyon, Maniere, Desilets)
| | - Étienne Désilets
- Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, Que. (Bergeron); Department of Gastroenterology, Hôpital Charles LeMoyne, Greenfield Park, Que. (Doyon, Maniere, Desilets)
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Bass GA, Kaplan LJ, Ryan ÉJ, Cao Y, Lane-Fall M, Duffy CC, Vail EA, Mohseni S. The snapshot audit methodology: design, implementation and analysis of prospective observational cohort studies in surgery. Eur J Trauma Emerg Surg 2023; 49:5-15. [PMID: 35840703 PMCID: PMC10606835 DOI: 10.1007/s00068-022-02045-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE For some surgical conditionns and scientific questions, the "real world" effectiveness of surgical patient care may be better explored using a multi-institutional time-bound observational cohort assessment approach (termed a "snapshot audit") than by retrospective review of administrative datasets or by prospective randomized control trials. We discuss when this might be the case, and present the key features of developing, deploying, and assessing snapshot audit outcomes data. METHODS A narrative review of snapshot audit methodology was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Manuscripts were selected from domains including: audit design and deployment, statistical analysis, surgical therapy and technique, surgical outcomes, diagnostic testing, critical care management, concomitant non-surgical disease, implementation science, and guideline compliance. RESULTS Snapshot audits all conform to a similar structure: being time-bound, non-interventional, and multi-institutional. A successful diverse steering committee will leverage expertise that includes clinical care and data science, coupled with librarian services. Pre-published protocols (with specified aims and analyses) greatly helps site recruitment. Mentored trainee involvement at collaborating sites should be encouraged through manuscript contributorship. Current funding principally flows from medical professional organizations. CONCLUSION The snapshot audit approach to assessing current care provides insights into care delivery, outcomes, and guideline compliance while generating testable hypotheses.
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Affiliation(s)
- Gary A Bass
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA.
- Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia, PA, USA.
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, 3400 Spruce St, 5 Dulles, Philadelphia, PA, 19104, USA.
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA
| | - Éanna J Ryan
- Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Yang Cao
- Department of Clinical Epidemiology and Biostatistics, Orebro University, Orebro, Sweden
| | - Meghan Lane-Fall
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, 3400 Spruce St, 5 Dulles, Philadelphia, PA, 19104, USA
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA, 19104, USA
| | - Caoimhe C Duffy
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, 3400 Spruce St, 5 Dulles, Philadelphia, PA, 19104, USA
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA, 19104, USA
| | - Emily A Vail
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, 3400 Spruce St, 5 Dulles, Philadelphia, PA, 19104, USA
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA, 19104, USA
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
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Wang CC, Chen SA, Cheng CT, Tee YS, Chan SY, Fu CY, Liao CA, Hsieh CH, Kuo LW. The role of acute care surgeons in treating rib fractures-a retrospective cohort study from a single level I trauma center. BMC Surg 2022; 22:271. [PMID: 35836219 PMCID: PMC9281009 DOI: 10.1186/s12893-022-01720-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/05/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Rib fractures are the most common thoracic injury in patients who sustained blunt trauma, and potentially life-threatening associated injuries are prevalent. Multi-disciplinary work-up is crucial to achieving a comprehensive understanding of these patients. The present study demonstrated the experience of an acute care surgery (ACS) model for rib fracture management from a single level I trauma center over 13 years. METHODS Data from patients diagnosed with acute rib fractures from January 2008 to December 2020 were collected from the trauma registry of Chang Gung Memorial Hospital (CGMH). Information, including patient age, sex, injury mechanism, Abbreviated Injury Scale (AIS) in different anatomic regions, injury severity score (ISS), index admission department, intensive care unit (ICU) length of stay (LOS), total admission LOS, mortality, and other characteristics of multiple rib fracture, were analyzed. Patients who received surgical stabilization of rib fractures (SSRF) were analyzed separately, and basic demographics and clinical outcomes were compared between acute care and thoracic surgeons. RESULTS A total of 5103 patients diagnosed with acute rib fracture were admitted via the emergency department (ED) of CGMH in the 13-year study period. The Department of Trauma and Emergency Surgery (TR) received the most patients (70.8%), and the Department of Cardiovascular and Thoracic Surgery (CTS) received only 3.1% of the total patients. SSRF was initiated in 2017, and TR performed fixation for 141 patients, while CTS operated for 16 patients. The basic demographics were similar between the two groups, and no significant differences were noted in the outcomes, including LOS, LCU LOS, length of indwelling chest tube, or complications. There was only one mortality in all SSRF patients, and the patient was from the CTS group. CONCLUSIONS Acute care surgeons provided good-quality care to rib fracture patients, whether SSRF or non-SSRF. Acute care surgeons also safely performed SSRF. Therefore, we propose that the ACS model may be an option for rib fracture management, depending on the deployment of staff in each institute.
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Affiliation(s)
- Chia-Cheng Wang
- grid.413801.f0000 0001 0711 0593Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing St., Guishan District, Taoyuan, 333 Taiwan
| | - Szu-An Chen
- grid.413801.f0000 0001 0711 0593Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing St., Guishan District, Taoyuan, 333 Taiwan
| | - Chi-Tung Cheng
- grid.413801.f0000 0001 0711 0593Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing St., Guishan District, Taoyuan, 333 Taiwan
| | - Yu-San Tee
- grid.413801.f0000 0001 0711 0593Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing St., Guishan District, Taoyuan, 333 Taiwan
| | - Sheng-Yu Chan
- grid.413801.f0000 0001 0711 0593Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing St., Guishan District, Taoyuan, 333 Taiwan
| | - Chih-Yuan Fu
- grid.413801.f0000 0001 0711 0593Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing St., Guishan District, Taoyuan, 333 Taiwan
| | - Chien-An Liao
- grid.413801.f0000 0001 0711 0593Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing St., Guishan District, Taoyuan, 333 Taiwan
| | - Chi-Hsun Hsieh
- grid.413801.f0000 0001 0711 0593Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing St., Guishan District, Taoyuan, 333 Taiwan
| | - Ling-Wei Kuo
- grid.413801.f0000 0001 0711 0593Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing St., Guishan District, Taoyuan, 333 Taiwan
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Quality of Care for Gallstone Pancreatitis-the Impact of the Acute Care Surgery Model and Hospital-Level Operative Resources. J Gastrointest Surg 2022; 26:849-860. [PMID: 34786665 DOI: 10.1007/s11605-021-05145-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/27/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Index cholecystectomy is the standard of care for gallstone pancreatitis. Hospital-level operative resources and implementation of an acute care surgery (ACS) model may impact the ability to perform index cholecystectomy. We aimed to determine the influence of structure and process measures related to operating room access on achieving index cholecystectomy for gallstone pancreatitis. METHODS In 2015, we surveyed 2811 US hospitals on ACS practices, including infrastructure for operative access. A total of 1690 hospitals (60%) responded. We anonymously linked survey data to 2015 State Inpatient Databases from 17 states using American Hospital Association identifiers. We identified patients ≥ 18 years who were admitted with gallstone pancreatitis. Patients transferred from another facility were excluded. Univariate and multivariable regression analyses, clustered by hospital and adjusted for patient factors, were performed to examine multiple structure and process variables related to achieving an index cholecystectomy rate of ≥ 75% (high performers). RESULTS Over the study period, 5656 patients were admitted with gallstone pancreatitis and 70% had an index cholecystectomy. High-performing hospitals achieved an index cholecystectomy rate of 84.1% compared to 58.5% at low-performing hospitals. On multivariable regression analysis, only teaching vs. non-teaching hospital (OR 2.91, 95% CI 1.11-7.70) and access to dedicated, daytime operative resources (i.e., block time) vs. no/little access (OR 1.93, 95% CI 1.11-3.37) were associated with high-performing hospitals. CONCLUSIONS Access to dedicated, daytime operative resources is associated with high quality of care for gallstone pancreatitis. Health systems should consider the addition of dedicated, daytime operative resources for acute care surgery service lines to improve patient care.
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Facundo HG, Montoliu RR, Llanos DRC, Naval GS, Millán EL, Gordo SL, Bosch JH, Rodríguez SL, Baranera MM, Martínez SG. Cholecystectomy 7 days vs 4 weeks after mild biliary pancreatitis; looking a decrease the incidence of persistent choledocholithiasis and ERCP: A multicentric randomized clinical trial. Int J Surg 2022; 98:106207. [PMID: 34995805 DOI: 10.1016/j.ijsu.2021.106207] [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: 08/20/2021] [Revised: 11/09/2021] [Accepted: 12/31/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Mild acute biliary pancreatitis (MABP) requires definitive treatment of the cholelithiasis to avoid recurrent biliary events. Recent publications recommend performing early surgery to prevent readmissions. However, an exceedingly early cholecystectomy could imply missing the presence of persistent choledocholithiasis or requiring a significant number of preoperative endoscopic retrograde cholangiopancreatographies (ERCP). This multicentre randomized clinical trial compares early surgery performed a week after MABP with delayed surgery (at 4 weeks), to compare readmission rates for recurrent biliary events and the incidence of residual choledocholithiasis between the two groups. MATERIALS AND METHODS A total of 198 patients with a first episode of MABP defined by the Atlanta 2012 criteria were enrolled. Randomization was done by a central study coordinator: 98 to early surgery and 100 to delayed surgery. All of them had preoperative or intraoperative imaging to exclude persistent choledocholithiasis. Laparoscopic cholecystectomy was performed by dedicated teams of experienced surgeons. RESULTS Early surgery reduced the rate of readmissions for biliary events before cholecystectomy by half (7.2% vs 15.8%, p = 0,058). There were no differences in the type of surgery, postoperative stay, or complications compared with delayed surgery. Choledocholithiasis was observed in 9.0% of patients in the early group and 7.7% in the delayed group (p 0,719). The preoperative or intraoperative imaging study avoided unnecessary ERCP, which was performed in only 6 (3%) patients. CONCLUSIONS Early cholecystectomy performed seven days after resolution of MABP had a low incidence of recurrent biliary events and complications, and was not associated with an increase in residual choledocholithiasis or need for unnecessary ERCP.
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Affiliation(s)
- Helena Gómez Facundo
- General and Digestive Surgery Department, Moisès Broggi Hospital, CSI, Barcelona, Spain General and Digestive Surgery Department, Sant Joan de Déu Hospital, Martorell, Barcelona, Spain General and Digestive Surgery Department, Joan XXIII Hospital, Tarragona, Spain General and Digestive Surgery Department, Consorci Sanitari Garraf, Sant Pere de Ribes, Barcelona, Spain General and Digestive Surgery Department, Consorci Sanitari Vic, Vic, Barcelona, Spain General and Digestive Surgery Department, Dos de Maig Hospital, Barcelona, Spain Epidemiology Department, Moisès Broggi Hospital, CSI, Barcelona, Spain
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Cienfuegos JA, Valentí V, Rotellar F. Acute pancreatitis: an opportunity for gastroenterology hospitalists? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:73-75. [PMID: 35040330 DOI: 10.17235/reed.2022.8573/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Due to the heterogeneous character of acute pancreatitis and its high incidence, it is imperative to follow clinical guidelines to avoid readmissions or recurrences. Implementing new hospital structures such as hospitalists in gastroenterology offer new possibilities to provide patient-centred value.
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Thiruvengadam NR, Saumoy M, Schneider Y, Attala S, Triggs J, Lee P, Kochman ML. A Cost-Effectiveness Analysis for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prophylaxis in the United States. Clin Gastroenterol Hepatol 2022; 20:216-226.e42. [PMID: 34481952 DOI: 10.1016/j.cgh.2021.08.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common adverse event after endoscopic retrograde cholangiopancreatography, and is responsible for substantial morbidity and health care expenditures of at least $200 million. Therapies for PEP prevention include pancreatic stent placement (PSP), rectal indomethacin, sublingual nitrates, and aggressive lactated Ringer's hydration. Our objective was to determine which PEP prophylactic strategies are cost effective. METHODS We developed 2 separate decision trees to evaluate PEP prophylactic strategies. The first, in high-risk patients, compared rectal indomethacin, PSP, PSP with indomethacin, sublingual nitrates, aggressive hydration with lactated Ringer's, and no prophylaxis. The second, in average-risk patients, compared rectal indomethacin, sublingual nitrates, aggressive hydration, and no prophylaxis. We used incidence rates, transition probabilities, and costs from publications and public data sources. Outcome measures were reported as incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life years (QALYs). RESULTS Compared with no prophylaxis, all strategies were cost effective at a WTP of $100,000 in preventing PEP in high-risk patients. When directly compared with each other, rectal indomethacin was the cost-effective strategy in high-risk patients ($31,589/QALYs). In average-risk patients, indomethacin and sublingual nitrates were cost effective at a WTP of $100,000/QALYs compared with no prophylaxis. When directly compared with each other, rectal indomethacin was the cost-effective strategy ($53,016/QALYs). CONCLUSIONS Rectal indomethacin was the cost-effective strategy for preventing PEP in both average-risk and high-risk patients undergoing endoscopic retrograde cholangiopancreatography. All strategies were cost effective when compared with no prophylaxis in high-risk patients, whereas all strategies except for aggressive hydration with lactated Ringer's were cost effective in average-risk patients. Further studies are needed to improve the utilization of PEP prevention strategies.
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California; Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Monica Saumoy
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Sara Attala
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Triggs
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Peter Lee
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael L Kochman
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Kinnear N, Jolly S, Herath M, Han J, Tran M, O'Callaghan M, Hennessey D, Dobbins C, Sammour T, Moore J. The acute surgical unit: An updated systematic review and meta-analysis. Int J Surg 2021; 94:106109. [PMID: 34536599 DOI: 10.1016/j.ijsu.2021.106109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/07/2021] [Accepted: 09/07/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To systematically review comparative studies on the acute surgical unit (ASU) model. METHODS Searches were performed of Cochrane, Embase, Medline and grey literature. Eligible articles were comparative studies of the Acute Surgical Unit (ASU) model published 01/01/2000-12/03/2020. Amongst patients with any diagnosis, primary outcomes were length of stay, after-hours operating, complications and cost. Secondary outcomes were time to surgical review, time to theatre, mortality and re-admission for patients with any diagnosis, and cholecystectomy during index admission for patients with biliary disease. Additional analyses were planned for specific cohorts, such as patients with appendicitis or cholecystitis. RESULTS Searches returned 9,677 results from which 77 eligible publications were identified, representing 150,981 unique patients. Cohorts were adequately homogenous for meta-analysis of all outcomes except cost. For patients with any diagnosis, compared with the Traditional model, the introduction of an ASU model was associated with reduced length of stay (mean difference [MD] 0.68 days; 95% confidence interval [CI] 0.38-0.98), after-hours operating rates (odds ratio [OR] 0.56; 95% CI 0.46-0.69) and complications (OR 0.48, 95% CI 0.33-0.70). Regarding cost, two studies reported savings following ASU introduction, while one found no difference. Amongst secondary outcomes, for patients with any diagnosis, ASU commencement was associated with reduced time to surgical review, time to theatre and mortality. Re-admissions were unchanged. For patients with biliary disease, ASU establishment was associated with superior rates of index cholecystectomy. CONCLUSION Compared to the Traditional structure, the ASU model is superior for most metrics. ASU introduction should be promoted in policy for widespread benefit.
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Affiliation(s)
- Ned Kinnear
- Adelaide Medical School, University of Adelaide, Adelaide, Australia Dept of Surgery, Royal Adelaide, Hospital, Adelaide, Australia Urology Unit, Flinders Medical Centre, Bedford Park, SA, Australia Flinders University, Adelaide, Australia Dept of Urology, Mercy University Hospital, Cork, Ireland
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11
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Value-Based Care for Gallstone Pancreatitis. J Am Coll Surg 2021; 233:524-525. [PMID: 34563328 DOI: 10.1016/j.jamcollsurg.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022]
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12
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Bergeron E, Desilets E, Maniere T, Bensoussan M. Same-day endoscopic ultrasound, retrograde cholangiopancreatography and stone extraction, followed by cholecystectomy: A case report and literature review. Int J Surg Case Rep 2020; 70:115-118. [PMID: 32416480 PMCID: PMC7229231 DOI: 10.1016/j.ijscr.2020.04.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/06/2020] [Accepted: 04/21/2020] [Indexed: 12/07/2022] Open
Abstract
The risk of recurrence or complications is high after a common bile duct stone related event. Cholecystectomy should be carried out soon after extraction of a common bile duct stone. Same-day investigation, endoscopic stone extraction and cholecystectomy is feasible and safe.
Introduction Common bile duct stone-related events and their recurrence are frequent even after endoscopic retrograde cholangiopancreatography and stone extraction. Cholecystectomy should be carried out as soon as possible after the initial episode to prevent complications. Case presentation We present a case of a patient who underwent endoscopic ultrasound, cholangiopancreatography with stone extraction and cholecystectomy on the same day. Discussion After a common bile duct stone-related event, investigation, and stone extraction, cholecystectomy should be carried out as soon as possible to avoid high rates of recurrence and complications. Rise in health care costs nowadays mandate such an approach as a pre-emptive measure to prevent health complications while lowering health costs. Conclusion Diagnosis of common bile duct stone followed by extraction with endoscopic cholangiopancreatography and cholecystectomy on the same day is feasible, safe, and has many potential advantages.
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Affiliation(s)
- Eric Bergeron
- Departments of Surgery and Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, Canada.
| | - Etienne Desilets
- Departments of Surgery and Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, Canada
| | - Thibaut Maniere
- Departments of Surgery and Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, Canada
| | - Michael Bensoussan
- Departments of Surgery and Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, Canada
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13
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Butler RJ, Grieve DA. Index cholecystectomy rates in mild gallstone pancreatitis: a single-centre experience. ANZ J Surg 2020; 90:2011-2014. [PMID: 32338824 DOI: 10.1111/ans.15887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/03/2020] [Accepted: 03/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gallstone pancreatitis (GSP) has evidence-based guidelines regarding management. Both the International Association of Pancreatology/American Pancreatology Association and American College of Gastroenterology recommend index admission cholecystectomy (IAC) in patients presenting with mild GSP. The aim of this study was to examine guideline adherence and GSP recurrence rate when IAC was not performed. A comparison between admitting specialty was also performed to examine the difference in compliance rates. METHODS A retrospective chart review was conducted on all patients who presented to the Sunshine Coast Hospital and Health Service with GSP from December 2013 to December 2016. Patient demographics, timing of surgery, admitting specialty, laboratory and imaging results were recorded. RESULTS A total of 95 patients were identified with a first presentation of mild GSP during the study period. Of whom, 66 (69.5%) underwent IAC and 29 (30.5%) were discharged prior to cholecystectomy with 10 of those patients receiving index admission endoscopic sphincterotomy. Five patients (17%) who did not receive IAC were readmitted with gallstone-related complications with the mean time to re-presentation of 12.8 days (range 7-21 days). Patients were more likely to receive IAC when admitted under surgery compared with gastroenterology (76% versus 20%, P < 0.001). CONCLUSION Two out of three patients presenting with mild GSP underwent IAC in accordance with evidence-based management guidelines. Patients should be admitted under a surgical service to prevent delay in definitive management.
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Affiliation(s)
- Reuban J Butler
- Department of General Surgery, Sunshine Coast University Hospital, Sunshine Coast Region, Queensland, Australia
| | - David A Grieve
- Department of General Surgery, Sunshine Coast University Hospital, Sunshine Coast Region, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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14
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Carmichael SP, Krebs JR, Mowery NT. Acute Care Surgery Model Leads to Shorter Length of Stay in Mild Gallstone Pancreatitis. Am Surg 2020. [DOI: 10.1177/000313482008600408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Samuel P. Carmichael
- Division of Acute Care Surgery Wake Forest Baptist Medical Center Winston-Salem, North Carolina
| | - Jonathan R. Krebs
- Department of Surgery University of Florida College of Medicine Gainesville, Florida
| | - Nathan T. Mowery
- Division of Acute Care Surgery Wake Forest Baptist Medical Center Winston-Salem, North Carolina
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15
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Koichopolos J, Hilsden R, Myslik F, Thompson D, Vandelinde J, Leeper R. Surgeon attitudes toward point of care ultrasound for biliary disease: a nationwide Canadian survey. CANADIAN JOURNAL OF SURGERY. JOURNAL CANADIEN DE CHIRURGIE 2020; 63:E9-E12. [PMID: 31916431 DOI: 10.1503.cjs/010218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Summary Multiple studies confirm that point of care ultrasound (PoCUS) has a high sensitivity and specificity for cholelithiasis and cholecystitis. However, there is poor perceived reliability of biliary PoCUS by surgeons. This survey was performed to assess surgeons’ opinions on using PoCUS in gallstone disease and barriers that exist for its institution. The majority (60.3%) of respondents reported a total lack of confidence in PoCUS for the diagnosis of biliary disease. Most felt the sensitivity of PoCUS was poor and had concerns about the user-dependent nature of the test and the lack of imaging details provided. If offered ideal clinical/laboratory findings with PoCUS results, only 4.7% of surgeons would definitely operate for unremitting biliary colic and 5.4% for cholecystitis. The ability to replicate findings independently increased confidence in clinical decision-making. Our findings suggest there is substantial distrust in biliary PoCUS but that specific ultrasound training for the surgical workforce may prove tremendously beneficial for its utilization.
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Affiliation(s)
- Jennifer Koichopolos
- From the Division of Emergency Medicine, Western University, London, Ont. (Thompson, Myslik); the Department of Surgery, Western University, London, Ont. (Koichopolos, Leeper); the Division of Critical Care Medicine, Western University, London, Ont. (Leeper); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Vandelinde)
| | - Richard Hilsden
- From the Division of Emergency Medicine, Western University, London, Ont. (Thompson, Myslik); the Department of Surgery, Western University, London, Ont. (Koichopolos, Leeper); the Division of Critical Care Medicine, Western University, London, Ont. (Leeper); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Vandelinde)
| | - Frank Myslik
- From the Division of Emergency Medicine, Western University, London, Ont. (Thompson, Myslik); the Department of Surgery, Western University, London, Ont. (Koichopolos, Leeper); the Division of Critical Care Medicine, Western University, London, Ont. (Leeper); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Vandelinde)
| | - Drew Thompson
- From the Division of Emergency Medicine, Western University, London, Ont. (Thompson, Myslik); the Department of Surgery, Western University, London, Ont. (Koichopolos, Leeper); the Division of Critical Care Medicine, Western University, London, Ont. (Leeper); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Vandelinde)
| | - Jeremy Vandelinde
- From the Division of Emergency Medicine, Western University, London, Ont. (Thompson, Myslik); the Department of Surgery, Western University, London, Ont. (Koichopolos, Leeper); the Division of Critical Care Medicine, Western University, London, Ont. (Leeper); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Vandelinde)
| | - Rob Leeper
- From the Division of Emergency Medicine, Western University, London, Ont. (Thompson, Myslik); the Department of Surgery, Western University, London, Ont. (Koichopolos, Leeper); the Division of Critical Care Medicine, Western University, London, Ont. (Leeper); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Vandelinde)
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16
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Zheng L, Deng J, Long X, Zeng Y. A patient with severe acute pancreatitis who was successfully rescued by multiple disciplinary teams: a case report. J Int Med Res 2019; 47:5831-5838. [PMID: 31547742 PMCID: PMC6862874 DOI: 10.1177/0300060519874156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Severe acute pancreatitis (SAP) is a type of acute abdominal disease. SAP has a high incidence, rapid progression, many complications, high mortality rate (as high as 30%–50%), and is difficult to treat, accounting for approximately 5% to 10% cases of acute pancreatitis. We report diagnosis and treatment of a case of SAP, including a combination of the relevant guidelines and our experience. The patient, who was a 42-year-old woman, was admitted to our hospital after suffering from abdominal pain in the upper abdomen for 1 day. The results of a computed tomography scan in the upper abdomen showed changes in the pancreas accompanied by acute fluid accumulation. The blood amylase level was 1150 U/L. The patient was treated at our Gastroenterology Department for 5.5 months, and received 22 blood transfusions (including red blood cell suspension, plasma, cryoprecipitate, and platelets), four surgical operations, three angiographic interventions, and two times of embolization for hemostasis. We successfully rescued this patient with SAP using minimally invasive, staged, multidisciplinary, and diversified treatment modalities.
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Affiliation(s)
- Linhui Zheng
- Emergency Trauma Center, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Deng
- Emergency Trauma Center, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xinhua Long
- Emergency Trauma Center, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuanlin Zeng
- Emergency Trauma Center, The First Affiliated Hospital of Nanchang University, Nanchang, China
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17
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Moody N, Adiamah A, Yanni F, Gomez D. Meta-analysis of randomized clinical trials of early versus delayed cholecystectomy for mild gallstone pancreatitis. Br J Surg 2019; 106:1442-1451. [PMID: 31268184 DOI: 10.1002/bjs.11221] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/14/2019] [Accepted: 04/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gallstones account for 30-50 per cent of all presentations of acute pancreatitis. While the management of acute pancreatitis is usually supportive, definitive treatment of gallstone pancreatitis is cholecystectomy. Guidelines from the British Society of Gastroenterology suggest definitive treatment on index admission or within 2 weeks of discharge, whereas joint recommendations from the International Association of Pancreatology and the American Pancreatic Association recommend definitive treatment on index admission. Evidence suggests that uptake of these guidelines is low. METHODS Embase, MEDLINE and Cochrane databases were searched for RCTs investigating early versus delayed cholecystectomy in patients with a confirmed diagnosis of mild gallstone pancreatitis. The pooled synthesis was undertaken using a random-effects meta-analysis of the primary outcome of recurrent biliary complications causing hospital readmission. Secondary outcomes included intraoperative and postoperative complications, and total length of hospital stay (LOS). All analyses were performed using RevMan5 software. RESULTS Five RCTs were identified, which included 629 patients (318 in the early cholecystectomy (EC) group and 311 in the delayed cholecystectomy (DC) group). Recurrent biliary events that required readmission were reduced in patients undergoing EC compared with the number in patients having DC (odds ratio (OR) 0·17, 95 per cent c.i. 0·09 to 0·33). There was no difference in the rate of intraoperative (OR 0·58, 0·17 to 1·92) or postoperative (OR 0·78, 0·38 to 1·62) complications. CONCLUSION EC following mild gallstone pancreatitis does not increase the risk of intraoperative or postoperative complications, but reduces the readmission rate for recurrent biliary complications.
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Affiliation(s)
- N Moody
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - A Adiamah
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - F Yanni
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - D Gomez
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
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18
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Symons NRA, McArthur D, Miller A, Verjee A, Senapati A. Emergency general surgeons, subspeciality surgeons and the future management of emergency surgery: results of a national survey. Colorectal Dis 2019; 21:342-348. [PMID: 30444316 DOI: 10.1111/codi.14474] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/30/2018] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to survey consultants' experience of working as or with emergency general surgery (EGS) surgeons and to investigate the role they fulfil in the management of general and subspeciality emergencies. METHOD An electronic survey, designed to capture both quantitative and qualitative data, was piloted and then circulated to members of the Association of Coloproctology of Great Britain and Ireland. RESULTS Two hundred and forty-two responses were received from 848 recipients (a 29% response rate) covering 104 of 135 (77%) acute NHS Trusts in England. EGS surgeons were in post in 43/141 (30%) hospitals overall and 12/24 (50%) of hospitals in London. Most respondents working in units with EGS surgeons found them to be advantageous (46/63, 73%). Consultants working with EGS surgeons were significantly more likely to support their use (49/63, 78%) than those without them (83/178, 47%) (χ2 = 16.9, P < 0.001). EGS surgeons were considered to improve the delivery of EGS (78%), create time for subspecialists (70%) and provide service (73%). However, there were concerns about the quality of surgery (43%), an insufficient standard of specialist care (54%) and compromise in the training of juniors (25%). Respondents commented on a lack of job structure with a high attrition rate (21%), the insufficient quality of applicants (18%) and that subspecialization and split on-call was preferable (17%). CONCLUSION Respondents were supportive of the ability of EGS surgeons to relieve pressure on subspecialists; however, there were significant concerns about the sustainability and quality of the EGS surgeon role. Emergency colorectal resections should have the input of a surgeon who performs elective colorectal resections.
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Affiliation(s)
- N R A Symons
- Imperial College London and Speciality Registrar in General Surgery, North East Thames, London, UK
| | - D McArthur
- Heart of England Foundation Trust, Birmingham, UK
| | - A Miller
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - A Verjee
- ACPGBI Patient Liaison Group, London, UK
| | - A Senapati
- ACPGBI EGS Working Group and Portsmouth Hospitals NHS Trust, Portsmouth, UK
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19
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Staplers vs. loop-ligature: a cost analysis from the hospital payer perspective. Surg Endosc 2019; 33:3419-3424. [PMID: 30604261 DOI: 10.1007/s00464-018-06639-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/19/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Presently, there is equipoise regarding the surgical technique used to manage the appendiceal stump during laparoscopic appendectomy. The purpose of this research was to determine whether the routine use of loop ligature, compared to stapling, is cost effective from a hospital payer perspective. METHODS A retrospective cohort study was conducted amongst patients undergoing emergency laparoscopic surgery for acute appendicitis at two major academic hospitals. In order to eliminate possible systematic bias arising from one technique being preferentially employed with more complex presentations, patients were divided into study groups based on the technique routinely employed by their surgeon, loop ligature (LLA) versus stapler (LSA). Pediatric patients and open appendectomies were excluded. Costs were determined using a previously published model derived from publicly available data from the Ontario Case Costing Initiative, in conjunction with local cost data for disposable procurement. Secondary outcomes included operating room time, length of stay, and complication rates. RESULTS Between Jan 1, 2014 and Dec 31, 2015, 567 adult patients had an emergency laparoscopic appendectomy for acute appendicitis. In comparing surgeons who routinely employed LLA to LSA, there was a significant decrease in total mean hospital cost with LLA ($1988 ± $143 vs. $2253 ± $99, p = 0.002). In addition, mean disposable cost was reduced for surgeons using LLA ($310 ± $27 vs. $668 ± $26, p < 0.001). This reduction in cost was not associated with a difference in length of stay (1.5 vs. 1.4 days, p = 0.28) or complication rates (8% vs. 10%, p = 0.43). CONCLUSIONS These findings suggest that surgeons who routinely use loop ligature to secure the appendiceal base during emergency laparoscopic appendectomy offer more cost-effective care compared to stapler users, saving their institution more than $200 per case with no clear disadvantages. A shift from routine use of staplers to loop ligature should result in significant overall cost savings to the hospital.
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20
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Acute Care Surgery Model and Outcomes in Emergency General Surgery. J Am Coll Surg 2019; 228:21-28.e7. [DOI: 10.1016/j.jamcollsurg.2018.07.664] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/17/2018] [Indexed: 11/19/2022]
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21
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Efficiency of care and cost for common emergency general surgery conditions: Comparison by surgeon training and practice. Surgery 2018; 164:651-656. [PMID: 30098814 DOI: 10.1016/j.surg.2018.05.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/16/2018] [Accepted: 05/31/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Our institutional emergency general surgery service is staffed by both trauma and critical care-trained surgeons and other boarded general surgeons and subspecialists. We compared efficiency of care for common emergency general surgery conditions between trauma and critical care-trained surgeons and boarded general surgeons and subspecialists. METHODS Adults admitted between February 2014 and May 2017 with acute appendicitis, acute cholecystitis, intestinal obstruction, incarcerated hernia, or other acute abdominal diagnoses seen by emergency general surgery service were included. Demographic characteristics, consulting surgeon, operations, outcomes, and cost data were obtained. RESULTS A total of 1,363 patients were included: 384 (28.2%) with acute appendicitis, 477 (35.0%) with acute cholecystitis, 406 (29.8%) with intestinal obstruction, 22 (1.6%) with incarcerated hernia, and 74 (5.4%) with other acute abdominal diagnoses. Trauma and critical care-trained surgeons saw 836 (61.3%) patients. There was no difference in operative management between the two groups, however, trauma and critical care-trained surgeons had significantly less time to the operative room (7.0 vs 12.9 hours; P < .001), without a difference in duration of stay or costs. The subgroups of acute appendicitis and acute cholecystitis when treated by trauma and critical care-trained surgeons had less time to the operative room (8.4 vs 17.4 hours; P < .001), shorter hospital stay (2.5 vs 2.8 days; P = .021), and less emergency department cost ($822 vs $876; P = .012). CONCLUSION Compared with boarded general surgeons and subspecialists, trauma and critical care-trained surgeons provide more efficient care for common emergency general surgery conditions, with less time from consultation to the operative room.
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22
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Reid GP, Williams EW, Francis DK, Lee MG. Acute pancreatitis: A 7 year retrospective cohort study of the epidemiology, aetiology and outcome from a tertiary hospital in Jamaica. Ann Med Surg (Lond) 2017; 20:103-108. [PMID: 28808565 PMCID: PMC5537196 DOI: 10.1016/j.amsu.2017.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is a significant cause of acute abdominal pain, morbidity and hospitalisation. There was previously a dearth of studies exploring the incidence, risk factors and outcome of AP in the Caribbean region. MATERIALS AND METHODS All patients with a diagnosis of AP admitted to the University Hospital of the West Indies (UHWI) between 2006 and 2012 were reviewed. The epidemiological profile, risk factors, clinical presentation and outcomes of patients with AP were retrospectively studied. RESULTS There were 70 females and 21 males with a median age of 44 years (range 2-86). The median age of males was significantly higher than that of females (p = 0.041). The incidence of AP was 74 per 100,000 admissions per year. Vomiting and abdominal tenderness were noted in the majority of patients. The most common aetiology was biliary disease (71.4%), idiopathic (12%), post-ERCP (6.6%) and alcohol (5.5%). Alcoholic pancreatitis was only seen in males whereas idiopathic and post-ERCP pancreatitis only occurred in females. The mean duration of hospitalisation was 9.51 ± 8.28 days. Disease severity was mild in 61.1%, moderately severe in 26.7%, and severe in 12.2% of patients. Factors associated with more severe disease included overweight/obesity, idiopathic aetiology and post-ERCP status. The case fatality rate was 2%. CONCLUSION The incidence of AP was 74/100,000 hospital admissions annually. There was an unusual female preponderance, with biliary pancreatitis being the most common type occurring at an equal frequency among males and females. Only 12.2% of the total cases seen were severe. The case fatality rate was 2%. Local health policy should target timely interventions for biliary pancreatitis and should also address the local factors affecting disease severity.
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Affiliation(s)
- Gail P Reid
- Emergency Medicine Division, Department of Surgery, Radiology, Anaesthesia & Intensive Care, The University Hospital of the West Indies, Mona, Jamaica
| | - Eric W Williams
- Emergency Medicine Division, Department of Surgery, Radiology, Anaesthesia & Intensive Care, The University Hospital of the West Indies, Mona, Jamaica
| | - Damian K Francis
- Epidemiology Research Unit, Caribbean Institute for Health Research, The University of the West Indies, Mona, Jamaica
| | - Michael G Lee
- Department of Medicine, The University Hospital of the West Indies, Mona, Jamaica
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