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Gelaw TT, Getahun MA, Bayih AM, Hailu KG, Tadesse GA, Adamu GL, Legesse MA. The impact of civil unrest on child health care: Evidenced by acute medical complications at presentation - A retrospective comparative study. PLoS One 2025; 20:e0320902. [PMID: 40202961 PMCID: PMC11981157 DOI: 10.1371/journal.pone.0320902] [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: 07/01/2024] [Accepted: 02/27/2025] [Indexed: 04/11/2025] Open
Abstract
BACKGROUND Civil unrest is a collective term that includes limited political violence, sporadic violent collective action, or nonviolent and mildly violent collective action that causes dissatisfaction over political, economic, or social changes. It had deadly impacts on the lives of children and adolescents. It often results in difficulties for civilian to access basic services including healthcare. OBJECTIVE Evaluate the effect of civil unrest on child healthcare provision evidenced by the proportion of children admitted with acute medical complications. METHODS Institution-based retrospective comparative study of Difference in Difference with Propensity Score Matching (PSM-DID) was implemented. SETTING AND PARTICIPANTS The study was conducted on children admitted to pediatric ward of Bahir Dar University Tibebe-Ghion specialized teaching hospital. Data were collected from medical records for the months of January 01, 2023 - July 31, 2023 (pre-civil unrest) and August 01, 2023 - February 29, 2024 (into the civil unrest), on a retrospective basis. 632 Participants (345 in the treatment and 247 in the control group) were selected randomly using Microsoft Excel based on their medical record number (MRN) from the HMIS registry with treatment assignment (rural residency or not). RESULTS PSM was conducted on 7 covariates. In the unmatched sample, significant differences between groups were found for two of the 7 covariates. PSM successfully adjusted for bias in all covariates in the matched sample. The civil unrest has increased acute medical complications at presentation to our hospital for rural residents, with a DID value of 0.241 (p-value = 0.009). CONCLUSION Our study has concluded that civil unrest has an immediate impact on child health care evidenced by an increased proportion of acute medical complications at presentation. It affects more children coming from rural areas compared to those from urban communities.
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Affiliation(s)
- Tesfaye Taye Gelaw
- Department of Pediatrics and Child Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Mensur Azeze Getahun
- Tibebe-Ghion Specialized Teaching Hospital, Bahir Dar University, Bahir Dar, Ethiopia
| | - Assefa Mitiku Bayih
- Tibebe-Ghion Specialized Teaching Hospital, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Gasha Amsalu Tadesse
- Tibebe-Ghion Specialized Teaching Hospital, Bahir Dar University, Bahir Dar, Ethiopia
| | - Gebeyaw Lulie Adamu
- Tibebe-Ghion Specialized Teaching Hospital, Bahir Dar University, Bahir Dar, Ethiopia
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2
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Rasslan S, Coimbra R, Rasslan R, Utiyama EM. Management of perforated peptic ulcer: What you need to know. J Trauma Acute Care Surg 2025:01586154-990000000-00935. [PMID: 40090948 DOI: 10.1097/ta.0000000000004561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2025]
Abstract
ABSTRACT Despite therapeutic advancements and the significant efficacy of medical management, peptic ulcer disease still affects millions of people. Elective surgical treatment, once a common intervention in General Surgery departments, is now nearly obsolete. Surgical treatment is reserved solely for complications, which occur in approximately 10% to 20% of cases. Perforation is the most common indication for surgery in peptic ulcer disease and accounts for nearly 40% of deaths from the disease. Treatment success depends on various factors, with early diagnosis and immediate surgical intervention being highlighted. Perforation is associated with a high incidence of morbidity and mortality. This article aims to analyze the different aspects related to the treatment of perforated peptic ulcers and define the best therapeutic approaches.
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Affiliation(s)
- Samir Rasslan
- From the Division of General Surgery and Trauma (S.R., R.R., E.M.U.), Faculdade de Medicina da Universidade de São Paulo, Brazil; Division of Acute Care Surgery and Comparative Effectiveness and Clinical Outcomes Research Center (CECORC) (R.C.), Riverside University Health System Medical Center, Moreno Valley; and Loma Linda University School of Medicine (R.C.), Loma Linda, California
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3
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Ikram S, Mirtorabi N, Ali D, Aain H, Naumann DN, Dilworth M. Does timely reporting of preoperative CT scans influence outcomes for patients following emergency laparotomy? Ann R Coll Surg Engl 2025; 107:146-150. [PMID: 38869096 PMCID: PMC11785439 DOI: 10.1308/rcsann.2023.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 06/14/2024] Open
Abstract
INTRODUCTION Timely preoperative computed tomography (CT) scans are important for patients requiring emergency laparotomy. United Kingdom guidelines state that a CT scan should be reported within 1h for 'critical' patients (will alter management at the time) and within 12h for 'urgent' patients (will alter management but not necessarily that day). METHODS An observational study included patients who were added to the National Emergency Laparotomy Audit (NELA) at a National Health Service trust from 2014 to 2021. The association of compliance with timings guidance and mortality was investigated. Multivariable logistic regression was used to determine the odds ratio of adherence to guidelines according to age, gender, night time admission, American Society of Anesthesiology (ASA) score, NELA mortality risk and category of scan. Further models determined the influence of adherence to guidelines on mortality, also adjusted for these variables. RESULTS There were 1,299 patients (48% 'critical' and 52% 'urgent' CT scans). Only 360/1,299 (28%) of scans were undertaken with adherence to the timing guidelines. Critical scans were less likely to adhere to guidelines. Although univariable analysis suggested that adherence to guidelines was associated with reduced mortality, this was not the case in the multivariable model: only age, ASA and NELA mortality risk remained significantly associated with mortality. CONCLUSIONS A minority of patients met the recommended preoperative CT report timings, and this was less likely for scans designated 'critical'. This did not appear to affect mortality when adjusted for key variables of risk. This illustrates the phenomenon of guideline adherence appearing to affect patient outcomes as a product of selection bias rather than causality.
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Affiliation(s)
- S Ikram
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - N Mirtorabi
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - D Ali
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - H Aain
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - DN Naumann
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - M Dilworth
- University Hospitals Birmingham NHS Foundation Trust, UK
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Sakowitz S, Bakhtiyar SS, Porter G, Mallick S, Oxyzolou I, Benharash P. Association of socioeconomic vulnerability with outcomes after emergency general surgery. Surgery 2024; 176:406-413. [PMID: 38796388 DOI: 10.1016/j.surg.2024.03.044] [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: 12/04/2023] [Revised: 02/18/2024] [Accepted: 03/21/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE Social determinants of health are increasingly recognized to shape health outcomes. Yet, the effect of socioeconomic vulnerability on outcomes after emergency general surgery remains under-studied. METHODS All adult (≥18 years) hospitalizations for emergency general surgery operations (appendectomy, cholecystectomy, laparotomy, large bowel resection, perforated ulcer repair, or small bowel resection), within 2 days of non-elective admission were tabulated in the 2016 to 2020 Nationwide Readmissions Database. Socioeconomic vulnerability was defined using relevant diagnosis codes and comprised economic, educational, healthcare, environmental, and social needs. Patients demonstrating socioeconomic vulnerability were considered Vulnerable (others: Non-Vulnerable). Multivariable models were constructed to evaluate the independent associations between socioeconomic vulnerability and key outcomes. RESULTS Of ∼1,788,942 patients, 177,764 (9.9%) were considered Vulnerable. Compared to Non-Vulnerable, Vulnerable patients were older (67 [55-77] vs 58 years [41-70), P < .001), more often insured by Medicaid (16.4 vs 12.7%, P < .001), and had a higher Elixhauser Comorbidity Index (4 [3-5] vs 2 [1-3], P < .001). After risk adjustment and with Non-Vulnerable as a reference, Vulnerable remained linked with a greater likelihood of in-hospital mortality (adjusted odds ratio 1.64, confidence interval 1.58-1.70) and any perioperative complication (adjusted odds ratio 2.02, confidence interval 1.98-2.06). Vulnerable also experienced a greater duration of stay (β+4.64 days, confidence interval +4.54-4.74) and hospitalization costs (β+$1,360, confidence interval +980-1,740). Further, the Vulnerable cohort demonstrated increased odds of non-home discharge (adjusted odds ratio 2.44, confidence interval 2.38-2.50) and non-elective readmission within 30 days of discharge (adjusted odds ratio 1.29, confidence interval 1.26-1.32). CONCLUSION Socioeconomic vulnerability is independently associated with greater morbidity, resource use, and readmission after emergency general surgery. Novel interventions are needed to build hospital screening and care pathways to improve disparities in outcomes.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO
| | - Giselle Porter
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Ifigenia Oxyzolou
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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5
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Quaile O, Perrodin SF, Trippel A, Schnüriger B. Characteristics of emergency general surgery services in Switzerland: a nationwide survey. Eur J Trauma Emerg Surg 2024; 50:259-268. [PMID: 37470790 PMCID: PMC10923733 DOI: 10.1007/s00068-023-02272-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/14/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Running an emergency general surgery (EGS) service is challenging and requires significant personnel and institutional resources. The aim of this study was to achieve a nationwide overview of the individual EGS service organizations in public hospitals in Switzerland. METHODS All Swiss public hospitals with a surgical and emergency department were included and contacted by telephone. General surgeons were interviewed between December 2021 and January 2022 using a standardized questionnaire. RESULTS Seventy-two out of 79 public hospitals in Switzerland (91.1%) agreed to the survey. They employed 1,581 surgeons in 19 (26.4%) hospitals with < 100 beds, 39 (54.2%) hospitals with 100-300 beds, 7 (9.7%) with 300-600 beds, and 7 (9.7%) with > 600 beds. The median number of surgeons per hospital was 20.5 (IQR 13.0-29.0). Higher level of care (intermediate or intensive care unit) was significantly less available in small hospitals (< 100 beds). The median hour of designated emergency operating room capacity per day was 14 h (IQR 14-24) for all hospitals with < 600 beds and 24 h (IQR 14-24) for the largest hospitals (> 600 beds). With increasing hospital size, there was a significant increase in the number of surgical units where EGS and orthopedic trauma surgery were covered by two separate teams (21.1% vs. 43.6% vs. 85.7% vs. 100%, p = 0.035). The median number of surgeons on-call per hospital and per 24 h was 5.0 (IQR 3.3-6.0). CONCLUSION Lack of higher level of care in small hospitals, limited emergency OR capacity and short rotations of on-call teams are major drawbacks of many current EGS systems in Switzerland. Centralization of critically ill EGS patients and reorganization of surgical on-call systems to designated acute care surgery teams should be considered.
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Affiliation(s)
- Oliver Quaile
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stéphanie Fabienne Perrodin
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Amedeo Trippel
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Nezerwa Y, Miranda E, Velin L, Shyaka I, Mukagaju F, Busomoke F, Nsanzimana JDD, Mukeshimana M, Mushimiyimana D, Mukambasabire B, Uwimana L, Ntirenganya F, Furaha C, Riviello R, Pompermaier L. Referral of Burn Patients in the Absence of Guidelines: A Rwandan Study. J Surg Res 2022; 278:216-222. [DOI: 10.1016/j.jss.2022.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 04/11/2022] [Accepted: 04/22/2022] [Indexed: 11/29/2022]
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Bouchard ME, Kan K, Tian Y, Casale M, Smith T, De Boer C, Linton S, Abdullah F, Ghomrawi HMK. Association Between Neighborhood-Level Social Determinants of Health and Access to Pediatric Appendicitis Care. JAMA Netw Open 2022; 5:e2148865. [PMID: 35171257 PMCID: PMC8851303 DOI: 10.1001/jamanetworkopen.2021.48865] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Presenting with complicated appendicitis, which is associated with higher rates of complications and readmissions compared with simple appendicitis, may indicate delayed access to care. Although both patient-level and neighborhood-level social determinants of health are associated with access to care, little is known about the association between neighborhood factors and access to acute pediatric surgical care. OBJECTIVE To examine the association between neighborhood factors and the odds of presenting with complicated appendicitis and unplanned postdischarge health care use. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of patients aged 18 years or younger diagnosed with appendicitis was conducted. Discharge data from October 1, 2015, to September 30, 2018, were obtained from the Pediatric Health Information System Database and linked to the Child Opportunity Index (COI) 2.0 Database. Data analysis was conducted from January 1 through July 1, 2021. EXPOSURES The COI, a composite score of zip code neighborhood opportunity level information, divided into quintiles ranging from very low to very high opportunity. MAIN OUTCOMES AND MEASURES Based on COI level, the main outcome was the odds of presenting with complicated appendicitis, which was defined using the Agency for Healthcare Research and Quality-specified International Statistical Classification of Diseases, 10th Edition, Clinical Modification codes. The secondary outcome was the odds of unplanned postdischarge health care use (emergency department visits and/or readmissions) for patients with simple and with complicated appendicitis. RESULTS A total of 67 489 patients (mean [SD] age, 10.5 [3.9] years) had appendicitis, with 31 223 cases (46.3%) being complicated. A total of 1699 patients (2.5%) were Asian, 24 234 (35.9%) were Hispanic, 4447 (6.6%) were non-Hispanic Black, and 29 234 (43.3%) were non-Hispanic White; 40 549 patients (60.1%) were male; and 32 343 (47.9%) were publicly insured. Patients living in very low-COI neighborhoods had 28% higher odds of presenting with complicated appendicitis (odds ratio, 1.28; 95% CI, 1.20-1.35) compared with those in very high-COI neighborhoods. There was no significant association between COI level and unplanned postdischarge health care use (very high COI, 20.8%; very low COI, 19.1%). CONCLUSIONS AND RELEVANCE In this cohort study, children from lower-COI neighborhoods had increased odds of presenting with complicated appendicitis compared with those from higher-COI neighborhoods, even after controlling for patient-level social determinants of health factors. These findings may inform policies and programs that seek to improve access to pediatric surgical care.
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Affiliation(s)
- Megan E. Bouchard
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Kristin Kan
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Yao Tian
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mia Casale
- Population Health Analytics, Division of Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Tracie Smith
- Population Health Analytics, Division of Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Christopher De Boer
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hassan M. K. Ghomrawi
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Okeke CJ, Okorie CO, Ojewola RW, Omoke NI, Obi AO, Egwu AN, Onyebum OV. Delay of Surgery Start Time: Experience in a Nigerian Teaching Hospital. Niger J Surg 2020; 26:110-116. [PMID: 33223807 PMCID: PMC7659763 DOI: 10.4103/njs.njs_61_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/24/2020] [Accepted: 03/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background: Operating room delay has multiple negative effects on the patients, surgical team, and the hospital system. Maximum utilization of the operating room requires on-time knife on the skin and efficient turnover. Knowledge of the reasons for the delay will form a basis toward proffering solutions. Patients and Methods: This was a prospective study of all consecutive elective cases done over a 15-month period from January 2016 to March 2017. Using our departmental protocol that “knife on skin” for the first elective case should be 8.00am, the delay was defined as a surgery starting later than 8.00am for the first cases while the interval between the cases of >30 min for the knife on the skin was used for subsequent cases. Reasons for delay in all cases of delay were documented. The prevalence and causes of the delays were analyzed. P < 0.05 was considered statistically significant. Results: Of 1178 surgeries performed during the period of study, 1170 (99.3%) of cases were delayed. The mean delay time was 151 min for all cases. First on the list had a longer delay time than others; 198.9 min versus 108.5 min (P = 0.000). Delay in the first cases accounted for 47.5% of all delayed cases. Overall, patient-related factor was the most common cause of delay (31.3%) followed in descending order by surgeon-related factor (28.5%) and hospital-related factor (26.2%). Patient-related factors accounted for 43.2% of first-case delays. Conclusion: Delays encountered in this study were multifactorial and are preventable. Efforts should be directed at these different causes of delay in the theater to mitigate these delays and improve productivity.
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Affiliation(s)
- Chike John Okeke
- Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria.,Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Surulere, Lagos, Nigeria
| | - Chukwudi Ogonnaya Okorie
- Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria.,Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
| | - Rufus Wale Ojewola
- Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Surulere, Lagos, Nigeria.,Department of Surgery, College of Medicine, University of Lagos, Idi-Araba, Surulere, Lagos, Nigeria
| | - Njoku Isaac Omoke
- Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria.,Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
| | - Anselm Okwudili Obi
- Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria.,Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
| | - Agama Nnachi Egwu
- Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria.,Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
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Ang ZH, Wong S, Truskett P. General Surgeons Australia's 12-point plan for emergency general surgery. ANZ J Surg 2019; 89:809-814. [PMID: 31280492 DOI: 10.1111/ans.15327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/13/2022]
Abstract
In the last decade, emergency general surgery (EGS) in Australia and New Zealand has seen a transition from the traditional on-call system to the acute surgical unit (ASU) model. The importance and growing demand for EGS has resulted in the implementation of the General Surgeons Australia's 12-point plan for emergency surgery. Since its release, the 12-point plan has been used as a benchmark of a well-functioning ASU, both locally and abroad. This study aims to provide a descriptive review on the relevance of the 12-point plan to the ASU model and review the current evidence to support this framework. The review concludes that the establishment of the ASU model has met the aims set out by the Royal Australasian College of Surgeons for EGS. The 12-point plan is relevant and has good evidence to support its framework.
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Affiliation(s)
- Zhen Hao Ang
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shing Wong
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Philip Truskett
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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10
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Teo A, Wang C, Wilson RB. Time is of the essence: evaluation of emergency department triage and time performance in the preoperative management of acute abdomen. ANZ J Surg 2019; 89:1102-1107. [PMID: 31115159 DOI: 10.1111/ans.15255] [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: 05/16/2018] [Revised: 03/12/2019] [Accepted: 03/31/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute abdomen is a time-critical condition, which requires prompt diagnosis, initiation of first-line preoperative therapy and expedient surgical intervention. The earliest opportunity to intervene occurs at presentation to the emergency department triage. The aim of this audit was to evaluate the relationship between emergency triage and time performance measures in the preoperative management of abdominal emergencies. METHODS Retrospective audit of time performance measures of key clinical events from emergency triage. Patient characteristics, elapsed time from triage to commencement of fluid resuscitation, intravenous antibiotics and emergency surgery and post-operative outcomes were obtained from review of operative medical records data over a 1-year duration. RESULTS There was variability in triage allocation of patients with acute abdomen requiring urgent surgery. Category 3 was the most commonly assigned triage category (65.6%). The majority of patients (94.8%) had initial clinical assessment within the National Emergency Access Target '4-hour' rule, and 41.7% seen within 1-h from triage. Despite this, in cases of intra-abdominal sepsis, there was nearly a fourfold elapsed time for first dose intravenous antibiotics, beyond the 1-h recommendation in the Sepsis Kills pathway. There was non-significant trend in faster overall time performances with successive higher triage category allocation. CONCLUSION This study highlights an opportunity to consider alternative triage methods or fast-track of patients with acute abdomen to promote early surgical assessment, resuscitation, antibiotic therapy and definitive intervention.
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Affiliation(s)
- Adrian Teo
- Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,The University of New South Wales, Sydney, New South Wales, Australia
| | - Cindy Wang
- Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Robert B Wilson
- Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,The University of New South Wales, Sydney, New South Wales, Australia
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11
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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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12
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Watters DA, Guest GD, Tangi V, Shrime MG, Meara JG. Global Surgery System Strengthening. Anesth Analg 2018; 126:1329-1339. [DOI: 10.1213/ane.0000000000002771] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Watters DA, Babidge WJ, Kiermeier A, McCulloch GAJ, Maddern GJ. Perioperative Mortality Rates in Australian Public Hospitals: The Influence of Age, Gender and Urgency. World J Surg 2017; 40:2591-2597. [PMID: 27255941 DOI: 10.1007/s00268-016-3587-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION A decline in surgical deaths has been observed in Australia since the introduction of the Australian and New Zealand Audit of Surgical Mortality (ANZASM). The current study was conducted to determine whether the perioperative mortality rate (POMR) has also declined. METHODS This study is a retrospective review of the POMR for surgical procedures in Australian public hospitals between July 2009 and June 2013, using data obtained from the Australian Institute of Health and Welfare. Operative procedures contained in the Australian Refined Diagnosis Related Groups were selected and the POMR was modelled using urgency of admission, age and gender as explanatory covariates. RESULTS The POMR in Australian public hospitals reduced by 15.4 % over the 4-year period. The emergency admissions POMR dropped from 1.40 to 1.12 %, and the elective admissions POMR from 0.09 to 0.08 %. The binary logistic regression model used to predict patient mortality showed emergency admissions to have a higher POMR than elective, being more evident at older ages. For emergency admissions, the difference in POMR between females and males increased with age, from about 55 years onwards, with females being lower. For elective surgeries, the difference between males and females was of little practical importance across ages. CONCLUSIONS The reduction in the POMR in Australia confirms the reduction in surgical deaths reported to ANZASM. Continuing to monitor POMR will be important to ensure the safest surgery in Australia. Further investigations into case-mix will allow better risk adjustment and comparison between regions and time-periods, to facilitate continuous quality improvement.
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Affiliation(s)
- David A Watters
- Research, Audit and Academic Surgery Division, Royal Australasian College of Surgeons, Spring St, Melbourne, VIC, 3000, Australia.
- Deakin University, Barwon Health, Bellerine St, Geelong, VIC, 3220, Australia.
| | - Wendy J Babidge
- Research, Audit and Academic Surgery Division, Royal Australasian College of Surgeons, Spring St, Melbourne, VIC, 3000, Australia
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Andreas Kiermeier
- Research, Audit and Academic Surgery Division, Royal Australasian College of Surgeons, Spring St, Melbourne, VIC, 3000, Australia
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Glenn A J McCulloch
- Research, Audit and Academic Surgery Division, Royal Australasian College of Surgeons, Spring St, Melbourne, VIC, 3000, Australia
| | - Guy J Maddern
- Research, Audit and Academic Surgery Division, Royal Australasian College of Surgeons, Spring St, Melbourne, VIC, 3000, Australia
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, SA, Australia
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Chen A, Retegan C, Vinluan J, Beiles CB. Potentially preventable deaths in the Victorian Audit of Surgical Mortality. ANZ J Surg 2016; 87:17-21. [PMID: 27758036 DOI: 10.1111/ans.13804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 08/23/2016] [Accepted: 08/29/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Victorian Audit of Surgical Mortality (VASM) seeks to peer-review all deaths associated with surgical care. This study aimed to examine the mortalities that were determined by the assessor to be potentially preventable, and identify the clinical factors associated with these cases. The assessment of preventability of death and its relationship to management issues at different stages of the admission episode, as opposed to whether the management issue(s) alone were preventable have not been reported previously. METHODS Mortality data from the VASM audit since 2007 that completed the peer-review process were retrospectively analysed. Mortalities identified as being preventable were assessed to determine any treatment errors. RESULTS A total of 6155 deaths were assessed. Of these, 14.6% (896/6155) were considered to be potentially preventable. Where a second-line assessment was requested (1113/6155, 17.5% cases), 48.3% of these deaths were considered potentially preventable. Elective patient deaths were more likely to be potentially preventable (P < 0.001), especially in public patients. Lack of timely involvement of senior staff, inappropriate treatment delay and failure of problem recognition were factors most frequently associated with potentially preventable mortality. CONCLUSION Overall assessment of the preventability of death is unique to VASM. This allows an additional level of analysis to be applied to the circumstances surrounding each mortality and correlation of preventability of death with clinical management issues provides important feedback to surgeons and health-care providers to further improve the safety and quality of care.
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Affiliation(s)
- Andrew Chen
- Victorian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Claudia Retegan
- Victorian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Jessele Vinluan
- Victorian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Charles Barry Beiles
- Victorian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
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15
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Clinical events reported by surgeons assessing their peers. Am J Surg 2016; 212:748-754. [DOI: 10.1016/j.amjsurg.2016.01.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/23/2015] [Accepted: 01/03/2016] [Indexed: 11/24/2022]
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Vester-Andersen M, Lundstrøm LH, Buck DL, Møller MH. Association between surgical delay and survival in high-risk emergency abdominal surgery. A population-based Danish cohort study. Scand J Gastroenterol 2016; 51:121-8. [PMID: 26153059 DOI: 10.3109/00365521.2015.1066422] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing emergency abdominal surgery in general. MATERIAL AND METHODS All in-patients aged ≥ 18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including surgical delay and 90-day mortality were collected. The crude and adjusted association between surgical delay by hour and 90-day mortality was assessed by binary logistic regression. RESULTS A total of 2803 patients were included. Median age (interquartile range [IQR]) was 66 (51-78) years, and 515 patients (18.4%) died within 90 days of surgery. Over the first 24 h after hospital admission, each hour of surgical delay beyond hospital admission was associated with a median (IQR) decrease in 90-day survival of 2.2% (1.9-3.3%). No statistically significant association between surgical delay by hour and 90-day mortality was shown; crude and adjusted odds ratio with 95% confidence interval 1.016 (1.004-1.027) and 1.003 (0.989-1.017), respectively. Sensitivity analyses confirmed the primary finding. CONCLUSIONS In the present population-based cohort study of high-risk patients undergoing emergency abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted.
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Affiliation(s)
- Morten Vester-Andersen
- a 1 Departments of Anaesthesiology and Intensive Care Medicine, Køge Hospital and Herlev Hospital , Herlev, Denmark
| | - Lars Hyldborg Lundstrøm
- b 2 Department of Anaesthesiology and Intensive Care Medicine, Nordsjællands Hospital , Hillerød, Denmark
| | - David Levarett Buck
- c 3 Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Rigshospitalet , Copenhagen, Denmark
| | - Morten Hylander Møller
- d 4 Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet , Copenhagen, Denmark
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Ong M, Guang TY, Yang TK. Impact of surgical delay on outcomes in elderly patients undergoing emergency surgery: A single center experience. World J Gastrointest Surg 2015; 7:208-213. [PMID: 26425270 PMCID: PMC4582239 DOI: 10.4240/wjgs.v7.i9.208] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/24/2015] [Accepted: 08/04/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To determine predisposing factors leading to surgical delay in elderly patients with acute abdominal conditions and its impact on surgical outcomes. METHODS A retrospective review of a total of 144 patients aged 60 years and older who had undergone emergency abdominal surgery between 2010 and 2013 at a regional general hospital was analysed. The operations analysed were limited to perforated or gangrenous viscus and strangulated hernia. Patient demographic features, time taken to obtain a computed tomography scan, time taken to surgery and the impact on postoperative morbidity and mortality were analysed. RESULTS The mean age was 70.5 ± 9.1 years and median time taken to surgery was 9 h. The overall mortality and complication rates (Clavien Dindo 3 and above) were 9% and 13.1% respectively. Diabetes mellitus was a significant predisposing factor which had an impact on surgical delays. Delays in surgery more than 24 h led to higher complication rates at 38.9% (P = 0.003), with multivariate analysis confirming it as an independent factor. Delays in obtaining a computed tomography (CT) scan was also shown to result in higher complication rates (Clavien Dindo 3 and above). CONCLUSION Delays in performing emergency surgery in elderly lead to higher complication rates. Obtaining CT scans early also may facilitate prompt diagnosis of certain abdominal emergencies where presentation is more equivocal and this may lead to improved surgical outcomes.
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Abstract
OBJECTIVE This article outlines the formation of the Australian and New Zealand Audit of Surgical Mortality (ANZASM) and describes its objectives, governance, functioning and challenges. BACKGROUND A nationwide audit of surgical mortality provides an overview of the leading causes of death in patients who require surgical care. It identifies system or process errors, trends in deficiency of care and helps develop strategies to reduce deaths in the surgical arena. METHODS A standardized tool is used to systematically collect data after every surgical death. Patient details are reviewed by a peer surgeon (and in certain cases a second) to identify issues with patient management and hospital processes. The treating surgeon is then offered confidential feedback and alternate views on patient management. RESULTS From January 2009 to December 2012, 19,096 deaths were reported to the ANZASM. Eighty-six percent of the audited deaths occurred in patients requiring an emergency admission. Significant criticism of patient care was reported in 13% of cases with 16% of clinical issues perceived to be preventable. Western Australia, which first began the audit process, has shown a 30% reduction in surgical deaths. CONCLUSIONS Nationwide mortality audits are a useful and worthwhile exercise. Recommendations identified in the audit reports direct educational workshops and seminars to address these issues. They allow Departments of Health to make informed decisions in their hospitals. Through this model, and the lessons learnt, we would encourage other countries planning to set up their own audits to follow a similar concept.
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Treacy PJ, North JB, Rey-Conde T, Allen J, Ware RS. Outcomes from the Northern Territory Audit of Surgical Mortality: Aboriginal deaths. ANZ J Surg 2015; 85:11-5. [PMID: 25365927 DOI: 10.1111/ans.12896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND A significant 'gap' in life expectancy exists for Australian Aboriginal people. The role of surgical care in this gap has been poorly addressed. This study has compared in-hospital surgical deaths of Aboriginal and non-Aboriginal persons in order to identify patient factors plus deficiencies of care that may have contributed to the gap. METHODS This study used retrospective data collection and prospective audit of all in-hospital surgical deaths since commencement of the Northern Territory Audit of Surgical Mortality (NTASM). Outcome measures included causes of death, coexisting factors and deficiencies of care. RESULTS Between June 2010 and June 2013, 190 deaths were audited (96% capture), of which 72 (38%) were Aboriginal. Aboriginal persons were younger at death (53 versus 65 years, P < 0.001) and had a higher incidence of diabetes (odds ratio = 2.8, 95% confidence interval: 1.4-5.6), renal (2.3, 1.1-4.7) and liver disease (5.7, 2.6-12.9). When adjusted for age and gender, serious cofactors were significantly more common in Aboriginal persons (3.8, 1.3-7.1). Rates of infections and all-cause trauma were comparable. There were no significant differences in the rates of complications, unplanned returns to theatre or intensive care unit, delays to surgery or whether in retrospect the surgeon considered management overall could have been improved. CONCLUSIONS A large gap of 12 years exists for age at death between Aboriginal and non-Aboriginal persons admitted as surgical patients in the Northern Territory. Aboriginal persons had significantly more co-morbidities at time of death, particularly diabetes, renal and hepatic disease. No significant discrepancies of surgical care were identified between Aboriginal and non-Aboriginal persons.
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Affiliation(s)
- Peter J Treacy
- Northern Territory Medical School, Flinders University, Darwin, Northern Territory, Australia
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20
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Beiles CB, Retegan C, Maddern GJ. Victorian Audit of Surgical Mortality is associated with improved clinical outcomes. ANZ J Surg 2014; 85:803-7. [PMID: 25039277 DOI: 10.1111/ans.12787] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Improved outcomes are desirable results of clinical audit. The aim of this study was to use data from the Victorian Audit of Surgical Mortality (VASM) and the Victorian Admitted Episodes Dataset (VAED) to highlight specific areas of clinical improvement and reduction in mortality over the duration of the audit process. METHODS This study used retrospective, observational data from VASM and VAED. VASM data were reported by participating public and private health services, the Coroner and self-reporting surgeons across Victoria. Aggregated VAED data were supplied by the Victorian Department of Health. Assessment of outcomes was performed using chi-squared trend analysis over successive annual audit periods. Because initial collection of data was incomplete in the recruitment phase, statistical analysis was confined to the last 3-year period, 2010-2013. RESULTS A 20% reduction in surgical mortality over the past 5 years has been identified from the VAED data. Progressive increase in both surgeon and hospital participation, significant reduction in both errors in management as perceived by assessors and increased direct consultant involvement in cases returned to theatre have been documented. CONCLUSIONS The benefits of VASM are reflected in the association with a reduction of mortality and adverse clinical outcomes, which have clinical and financial benefits. It is a purely educational exercise and continued participation in this audit will ensure the highest standards of surgical care in Australia. This also highlights the valuable collaboration between the Victorian Department of Health and the RACS.
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Affiliation(s)
- C Barry Beiles
- Victorian Audit of Surgical Mortality, Royal Australasian College of Surgeons, East Melbourne, Victoria, Australia
| | - Claudia Retegan
- Victorian Audit of Surgical Mortality, Royal Australasian College of Surgeons, East Melbourne, Victoria, Australia
| | - Guy J Maddern
- Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, East Melbourne, Victoria, Australia.,Department of Surgery, The University of Adelaide and The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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21
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Vinluan J, Retegan C, Chen A, Beiles CB. Clinical management issues vary by specialty in the Victorian Audit of Surgical Mortality: a retrospective observational study. BMJ Open 2014; 4:e005554. [PMID: 24980043 PMCID: PMC4078770 DOI: 10.1136/bmjopen-2014-005554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Clinical management issues are contributory factors to mortality. The aim of this study was to use data from the Victorian Audit of Surgical Mortality (VASM), an educational peer-review process for surgeons, to discover differences in the incidence of these issues between surgical specialties in order to focus attention to areas of care that might be improved. DESIGN This study used retrospectively analysed observational data from VASM. Clinical management issues between eight specialties were assessed using χ(2) analysis. DATA SOURCES VASM data were reported by participating public and private health services, the Coroner and self-reporting surgeons across Victoria. RESULTS A total of 2946 specific clinical issues as deficiencies of care were reported. 15% of cases had significant issues of care. The most common clinical management issue was the delay in delivery of treatment. Other clinical issues included the quality of communication and documentation, preoperative and postoperative care, adverse events and protocol issues. There were significant differences in issues between specialties. CONCLUSIONS The clinical management issues presented across surgical specialties were similar; however, five issues of clinical care differed significantly in frequency across surgical specialties. The three main issues varying among specialties were complications after operation, communication and postoperative care. Addressing these clinical management issues via the peer-review process may impact positively on patient care.
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Affiliation(s)
- Jessele Vinluan
- Victorian Audit of Surgical Mortality (VASM), Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Claudia Retegan
- Victorian Audit of Surgical Mortality (VASM), Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Andrew Chen
- Victorian Audit of Surgical Mortality (VASM), Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Charles Barry Beiles
- Victorian Audit of Surgical Mortality (VASM), Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
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Watters DA, Hollands MJ, Gruen RL, Maoate K, Perndt H, McDougall RJ, Morriss WW, Tangi V, Casey KM, McQueen KA. Perioperative Mortality Rate (POMR): A Global Indicator of Access to Safe Surgery and Anaesthesia. World J Surg 2014; 39:856-64. [DOI: 10.1007/s00268-014-2638-4] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Buck DL, Møller MH. Influence of body mass index on mortality after surgery for perforated peptic ulcer. Br J Surg 2014; 101:993-9. [PMID: 24828155 DOI: 10.1002/bjs.9529] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 12/03/2013] [Accepted: 03/11/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Body mass index (BMI) is a strong predictor of mortality in the general population. In spite of the medical hazards of obesity, a protective effect on mortality has been suggested in surgical patients: the obesity paradox. The aim of the present nationwide cohort study was to examine the association between BMI and mortality in patients treated surgically for perforated peptic ulcer (PPU). METHODS This was a national prospective cohort study of all Danish patients treated surgically for PPU between 1 February 2003 and 31 August 2009, for whom BMI was registered. Non-surgically treated patients and those with malignant ulcers were excluded. The primary outcome measure was 90-day mortality. The association between BMI and mortality was calculated as crude and adjusted relative risks (RRs) with 95 per cent confidence intervals (c.i.). RESULTS Of 2668 patients who underwent surgical treatment for PPU, 1699 (63.7 per cent) had BMI recorded. Median age was 69.4 (range 17.6-100.9) years and 53.7 per cent of the patients were women. Some 1126 patients (66.3 per cent) had at least one of six co-morbid diseases; 728 (42.8 per cent) had an American Society of Anesthesiologists grade of III or more. A total of 471 patients (27.7 per cent) died within 90 days of surgery. Being underweight was associated with a more than twofold increased risk of death following surgery for PPU (adjusted RR 2.26, 95 per cent c.i. 1.37 to 3.71). No statistically significant association was found between obesity and mortality. CONCLUSION Being underweight was associated with increased mortality in patients with PPU, whereas being overweight or obese was neither protective nor an adverse prognostic factor.
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Affiliation(s)
- D L Buck
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Herlev
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24
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Raju RS, Guy GS, Field JBF, Kiroff GK, Babidge W, Maddern GJ. Australian and New Zealand Audit of Surgical Mortality: concordance between reported and audited clinical events and delays in management in surgical mortality patients. ANZ J Surg 2014; 84:618-23. [PMID: 24754257 DOI: 10.1111/ans.12642] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Australian and New Zealand Audit of Surgical Mortality (ANZASM) is a nationwide confidential peer review of deaths associated with surgical care. This study assesses the concordance between treating surgeons and peer reviewers in reporting clinical events and delays in management. METHODS This is a retrospective cross-sectional analysis of deaths in 2009 and 2010. Cases that went through the process of submission of details by the surgeon in a structured surgical case form (SCF), first-line assessment (FLA) and a more detailed second-line assessment (SLA) were included. Significant clinical events reported for these patients were categorized and analysed for concordance. RESULTS Of the 11,303 notifications of death to the ANZASM, 6507 (57.6%) were audited and 685 (10.5%) required the entire review process. Nationally, the most significant events were post-operative complications, poor preoperative assessment and delay to surgery or diagnosis. The SCF submissions reported 338 events, as compared with 1009 and 985 events reported through FLA and SLA, respectively (P = 0.01). Treating surgeons and assessors attributed 29-30% of events to factors outside the surgeon's control. Surgeons felt that delay to surgery or diagnosis was a significant event in 6.6% of cases, in contrast to 20% by assessors (P = 0.01). Preoperative management could be improved in 19% of cases according to surgeons, compared with 45 and 36% according to the assessors (P < 0.001). CONCLUSION There is significant discordance between treating surgeons and assessors. This suggests the need for in-depth analysis and possible refinement of the audit process.
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Affiliation(s)
- Ravish S Raju
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
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25
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Ifesanya AO, Ogundele OJ, Ifesanya JU. Orthopaedic surgical treatment delays at a tertiary hospital in sub Saharan Africa: Communication gaps and implications for clinical outcomes. Niger Med J 2014; 54:420-5. [PMID: 24665159 PMCID: PMC3948967 DOI: 10.4103/0300-1652.126301] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Delay in surgical treatment is a source of distress to patients and an important reason for poor outcome. We studied the delay before carrying out scheduled operative orthopaedic procedures and the factors responsible for it. Materials and Methods: This prospective study was carried out between March 2011 and December 2012. Temporal details of the surgical procedures at our hospital were recorded in a proforma including the patients’ perception of the causes of the delay to surgery. Based on the urgency of the need for surgery, patients were classified into three groups using a modification of the method employed by Lankester et al. Data was analyzed using the Statistical Package for the Social Sciences, version 17.0. Predictors of surgical delay beyond 3 days were identified by logistic regression analysis. Results: Two hundred and forty-nine patients with a mean age 36.2 ± 19.2 years and M:F ratio 1.3 were recruited. 34.1% were modified Lankester group A, 45.4% group B and 20.5% group C. 47 patients (18.9%) had comorbidities, hypertension being the commonest (22 patients; 8.8%). Median delay to surgery was 4 days (mean = 17.6 days). Fifty percent of emergency room admissions were operated on within 3 days, the figure was 13% for other admissions. Lack of theatre slot was the commonest cause of delay. There was full concordance between doctors and patients in only 70.7% regarding the causes of the delay. In 15.7%, there was complete discordance. Logistic regression analysis confirmed modified Lankester groups B and C (P = 0.003) and weekend admission (P = 0.016) as significant predictors of delay to surgery of >3 days. Conclusion: Promptness to operative surgical care falls short of the ideal. Theatre inefficiency is a major cause of delay in treating surgical patients in our environment. Theatre facilities should be expanded and made more efficient. There is a need for better communication between surgeons and patients about delays in surgical treatment.
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Affiliation(s)
- Adeleke O Ifesanya
- Department of Orthopaedics and Trauma, University College Hospital, Ibadan, Nigeria
| | - Olumuyiwa J Ogundele
- Department of Orthopaedics and Trauma, University College Hospital, Ibadan, Nigeria
| | - Joy U Ifesanya
- Department of Child Oral Health, University College Hospital, Ibadan, Nigeria
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Buck DL, Vester-Andersen M, Møller MH. Surgical delay is a critical determinant of survival in perforated peptic ulcer. Br J Surg 2013; 100:1045-9. [DOI: 10.1002/bjs.9175] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2013] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Morbidity and mortality following perforated peptic ulcer (PPU) remain substantial. Surgical delay is a well established negative prognostic factor, but evidence derives from studies with a high risk of bias. The aim of the present nationwide cohort study was to evaluate the adjusted effect of hourly surgical delay on survival after PPU.
Methods
This was a cohort study including all Danish patients treated surgically for PPU between 1 February 2003 and 31 August 2009. Medically treated patients and those with a malignant ulcer were excluded. The associations between surgical delay and 30-day survival are presented as crude and adjusted relative risks (RRs) with 95 per cent confidence intervals (c.i.).
Results
A total of 2668 patients were included. Their median age was 70·9 (range 16·2–104·2) years and 55·4 per cent (1478 of 2668) were female. Some 67·5 per cent of the patients (1800 of 2668) had at least one of six co-morbid diseases and 45·6 per cent had an American Society of Anesthesiologists fitness grade of III or more. A total of 708 patients (26·5 per cent) died within 30 days of surgery. Every hour of delay from admission to surgery was associated with an adjusted 2·4 per cent decreased probability of survival compared with the previous hour (adjusted RR 1·024, 95 per cent c.i. 1·011 to 1·037).
Conclusion
Limiting surgical delay in patients with PPU seems of paramount importance.
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Affiliation(s)
- D L Buck
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - M Vester-Andersen
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - M H Møller
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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