Acute Surgical Unit Research Articles

Torsion of the gallbladder leading to gangrene: A case report and literature review

Gallbladder torsion is a rare but potentially catastrophic presentation to an acute surgical unit. It was first described by Wendel in 1898 where this presentation was labelled as a ‘floating gallbladder’, with a high propensity for perforation1. Since then approximately 500 cases have been reported in the literature2. Anatomically, gallbladder torsion occurs where the gallbladder rotates along its mesentery causing vascular compromise and obstruction to biliary drainage. This leads to subsequent necrosis and perforation3. Shaikh A. et al have reiterated that the entire aetiological sequence of gallbladder torsion continues to remains a debated topic although, generally, a redundant mesentery is required for torsion to occur4. In most reported cases, the gallbladder has been shown to undergo a clockwise rotation 5. As described later, this presentation has predominantly been reported in elderly females suggesting that age plays a role in anatomically predisposing to torsion. Factors hypothesised for this include decrease in visceral fat and liver atrophy making free movement of the gallbladder and ultimately volvulus more likely to occur6. The symptoms of gallbladder torsion are in keeping with those of cholecystitis, typically presenting with right upper quadrant pain, nausea and vomiting 2. Clinical examinations of previously reported cases have documented abdominal distention, right upper quadrant pain and localised peritonitis2. These non-specific signs can make this specific phenomenon a challenge to diagnose in clinical practice. It has been documented that a partial volvulus can present with intermittent symptoms, similar to those seen in biliary colic, although the majority of cases will present acutely with signs described above 3. Due to the relatively low numbers reported in the literature it is difficult to determine the most appropriate investigations in patients where this is expected. Classically, patients presenting with right upper quadrant pain will likely receive an abdominal ultrasound on admission. From the cases reported we have found that a range of investigations have been implemented in practice including ultrasound and computed tomography (CT), although this diagnosis is often pragmatically difficult to diagnose based on imaging alone 3. Non-specific findings of gallbladder inflammation have been reported in cases of gallbladder torsion including gallbladder wall thickening and fluid collections surrounding the gallbladder neck 7. Other imaging modalities useful in pre-operative diagnosis include Magnetic Resonance Cholangiopancreatography (MRCP) which may show tapering and twisting of the cystic duct 3, 8. Interestingly, gallbladder calculi have not been considered a causative factor and where present in less than a third of patients carrying this diagnosis in a review performed by Reilly et al 5, 9. Other baseline investigations including white cell count, CRP and liver function tests have been shown to be relevant in diagnosing the acute abdomen. However, these are generally non-specific as a predictor for gallbladder volvulus. Reilly et al performed a systematic review of 324 cases shown in the literature between 1898 and 2011 9. From this the predominant risk factors associated with gallbladder volvulus include female sex, age over 60 years and patients with several comorbidities 9 Previous authors have suggested that female to male ratios in presentation are approximately 4:1, although the condition is more prevalent in males in children 10. Management of this condition is primarily surgical and the reports published show that these patients are mainly treated by cholecystectomy. In general, this is done laparoscopically in experienced hands where this presentation is identified 3, 4, 9. It has been suggested that the gallbladder should first be decompressed if distended to allow for a more straightforward removal 3. There has also been a case reported managed with ERCP although this is not the preferred method of managing this condition 11. Prognosis of this condition is dependent on several factors. The literature has demonstrated that those patients with a pre-operative diagnosis have more favourable outcomes 9. Reilley et al suggested from their review that overall mortality was approximately 6% 9. In this report we discuss the case of gallbladder torsion managed at a large district hospital in North East England.

Modified frailty index and hypoalbuminemia as predictors of adverse outcomes in older adults presenting to acute general surgical unit

IntroductionHealth professionals are progressively drawing on the concept of frailty as a determinant of adverse surgical outcomes in of older adults. We aimed to determine the prevalence of frailty and the correlation between frailty and mortality among older adults admitted to the acute surgical unit. Materials and methodsThis prospective cohort study was conducted in the acute general surgical unit over a two month period. We recruited 150 consecutive patients aged 65yrs and above. The modified frailty index was employed to measure frailty and the albumin levels on admission were obtained from electronic medical records. The patients were followed up for a period of thirty days. ResultsWe found that more than 40% of the older adults admitted to the acute general surgical unit were frail and frailty was associated with higher rate of mortality at 30 days. Hypoalbuminemia was associated with a longer length of stay, higher rate of complications, and an increased likelihood of discharge to a rehabilitation facility. There was also a significant univariate correlation between frailty and the presence of hypoalbuminemia on admission. ConclusionFrailty and hypoalbuminemia are common in older general surgical patients and predict the likelihood of some of the adverse outcomes relevant to older adults and health economy such as mortality, increased length of stay, rate of complications, and likelihood of discharge to a rehabilitation facility. Further studies should investigate a possible causal association between frailty and low albumin levels in an acute surgical setting.

Does emergency general surgery model affect staff satisfaction, training and working hours?

Few studies have assessed the relationship between different emergency general surgery models and staff satisfaction, operative experience or working hours. The Royal Australasian College of Surgeons recommends maximum on-call frequency of one-in-four for surgeons and registrars. A cross-sectional study was conducted of all medium- to major-sized Australian public hospitals offering elective general surgery. At each site, an on-call general surgery registrar and senior surgeon were invited to participate. Primary outcomes were staff satisfaction and registrar-perceived operative exposure. Secondary outcomes were working hours. Among eligible hospitals, 119/120 (99%) were enrolled. Compared with traditional emergency general surgery models, hybrid or acute surgical unit models were associated with greater surgeon and registrar satisfaction on quantitative (P = 0.012) and qualitative measures. Registrar-perceived operating exposure was unaffected by emergency general surgery model. Longest duration on-duty was higher among traditional structures for both registrars (mean 22 versus 15 h; P = 0.0003) and surgeons (mean 59 versus 41 h; P = 0.020). On-call frequency greater than one-in-four was more common in traditional structures for registrars (51% versus 28%; P = 0.012) but not surgeons (6% versus 0%; P = 0.089). Data on average hours per day off-duty were obtained for registrars only, and were lower in traditional structures (13 versus 15 h; P = 0.00002). Hybrid or acute surgical unit models may improve staff satisfaction without sacrificing perceived operative exposure. While average maximum duration on-duty exceeded hazardous thresholds for surgeons regardless of model, unsafe working hours for registrars were more common in traditional structures. General surgical departments should review on-call rostering to optimize staff and patient safety.

Communication and management of incidental pathology in 1,214 consecutive appendicectomies; a cohort study.

Important incidental pathology requiring further action is commonly found during appendicectomy, macro- and microscopically. We aimed to determine whether the acute surgical unit (ASU) model improved the management and disclosure of these findings. An ASU model was introduced at our institution on 01/08/2012. In this retrospective cohort study, all patients undergoing appendicectomy 2.5 years before (Traditional group) or after (ASU group) this date were compared. The primary outcomes were rates of appropriate management of the incidental findings, and communication of the findings to the patient and to their general practitioner (GP). 1,214 patients underwent emergency appendicectomy; 465 in the Traditional group and 749 in the ASU group. 80 (6.6%) patients (25 and 55 in each respective period) had important incidental findings. There were 24 patients with benign polyps, 15 with neuro-endocrine tumour, 11 with endometriosis, 8 with pelvic inflammatory disease, 8 Enterobius vermicularis infection, 7 with low grade mucinous cystadenoma, 3 with inflammatory bowel disease, 2 with diverticulitis, 2 with tubo-ovarian mass, 1 with secondary appendiceal malignancy and none with primary appendiceal adenocarcinoma. One patient had dual pathologies. There was no difference between the Traditional and ASU group with regards to communication of the findings to the patient (p = 0.44) and their GP (p = 0.27), and there was no difference in the rates of appropriate management (p = 0.21). The introduction of an ASU model did not change rates of surgeon-to-patient and surgeon-to-GP communication nor affect rates of appropriate management of important incidental pathology during appendectomy.

Patient experience in a surgical assessment unit following a closed-loop audit using a Kaizen Lean system.

The Acute Surgical Assessment Unit (ASAU) in University Hospital Limerick (UHL) has provided a solution to overcrowding and long waiting times since centralization of emergency services to UHL. Recognising the importance of its evolving role, the ASAU in UHL has recently undergone a major revamp to ease the pressure in the overcrowded emergency department (ED). This included a new purpose state-of-the-art-built unit and equipment, improved staffing levels and use of a Kaizen Lean system to identify key area of delays and inefficiency with subsequent implementation of suggestions derived after Kaizen Lean. Patient satisfaction reporting was analysed in the older building and subsequently in the new site post Kaizen Lean to complete a closed-loop audit. The aim of the study was to examine patient satisfaction response rates with the ASAU prior to and following Kaizen Lean implementation and transfer to a new purpose-built unit. The survey comprised of two phases. In phase 1, 100 questionnaires were distributed to patients in ASAU (older building, pre-Kaizen Lean). In phase 2, the survey was repeated (100 patients) after Kaizen Lean implementation and transfer to the new state-of-the-art unit. Questionnaire design was based on WHO strategy on responsiveness measurement guidelines and was tailored to a population of surgical patients. Results were analysed using IBM SPSS, version 21 and Excel 2013. Two hundred questionnaires were analysed. Implementation of suggestions derived post Kaizen Lean translated into improved resource usage with reduced waiting time to be seen by nurses and doctors. Patients had better awareness about their treatment plan and planned next steps in the management. Satisfaction across different domains, perceptions of privacy and overall treatment were also improved. A Kaizen Lean approach improved the transition of an ASAU to a new purpose-built unit and further improved overall patient satisfaction with services of the ASAU.

Lessons learned from relocating an acute surgical unit to a new quaternary referral centre in Adelaide, South Australia: a tale of two hospitals.

On 4 September 2017, patient care was relocated from one quaternary hospital that was closing, to another proximate greenfield site in Adelaide, Australia, this becoming the new Royal Adelaide Hospital. There are currently no data to inform how best to transition hospitals. We conducted a 12-week prospective study of admissions under our acute surgical unit to determine the impact on our key performance indicators. We detail our results and describe compensatory measures deployed around the move. Using a standard proforma, data were collected on key performance indicators for acute surgical unit patients referred by the emergency department (ED). This was supplemented by data obtained from operative management software and coding data from medical records to build a database for analysis. Five hundred and eight patients were admitted during the study period. Significant delays were seen in times to surgical referral, surgical review and leaving the ED. Closely comparable was time spent in the surgical suite. Uptake of the Ambulatory Care Pathway fell by 67% and the Rapid Access Clinic by 46%. Overall mortality and patient length of stay were not affected. We found the interface with ED was most affected. Staff encountered difficulties familiarizing with a new environment and an anecdotally high number of ED presentations. Delays to referral and surgical review resulted in extended patient stay in ED. Once in theatre, care was comparable pre- and post-transition. This was likely from early identification of patients requiring an emergency operation, close consultant surgeon involvement and robust working relationships between surgeons, anaesthetists and nurses.

Comparison of Automated Sepsis Identification Methods and Electronic Health Record-based Sepsis Phenotyping: Improving Case Identification Accuracy by Accounting for Confounding Comorbid Conditions.

Retrospective cohort study of emergency department and in-hospital patient encounters from 2014 to 2018. One community and two academic hospitals in Maryland. All patients 18 years old or older presenting to the emergency department or admitted to any acute inpatient medical or surgical unit including patients discharged from the emergency department. None. From the electronic health record, 233,252 emergency department and inpatient encounters were identified. Patient data were used to develop and validate electronic health record-based sepsis phenotyping, an adaptation of "the Centers for Disease Control Adult Sepsis Event toolkit" that accounts for comorbid conditions when identifying sepsis patients. The performance of this novel system was then compared with 1) physician case review and 2) three other commonly used strategies using metrics of sensitivity and precision relative to sepsis billing codes, termed "billing code sensitivity" and "billing code predictive value." Physician review of electronic health record-based sepsis phenotyping identified cases confirmed 79% as having sepsis; 88% were confirmed or had a billing code for sepsis; and 99% were confirmed, had a billing code, or received at least 4 days of antibiotics. At comparable billing code sensitivity (0.91; 95% CI, 0.88-0.93), electronic health record-based sepsis phenotyping had a higher billing code predictive value (0.32; 95% CI, 0.30-0.34) than either the Centers for Medicare and Medicaid Services Sepsis Core Measure (SEP-1) definition or the Sepsis-3 consensus definition (0.12; 95% CI, 0.11-0.13; and 0.07; 95% CI, 0.07-0.08, respectively). When compared with electronic health record-based sepsis phenotyping, Adult Sepsis Event had a lower billing code sensitivity (0.75; 95% CI, 0.72-0.78) and similar billing code predictive value (0.29; 95% CI, 0.26-0.31). Electronic health record-based sepsis phenotyping identified patients with higher in-hospital mortality and nearly one-half as many false-positive cases when compared with SEP-1 and Sepsis-3. By accounting for comorbid conditions, electronic health record-based sepsis phenotyping exhibited better performance when compared with other automated definitions of sepsis.

An Acute General Surgical Unit (AGSU) Negates the Impact of the Tokyo Guidelines 2018 (TG18) Diagnostic Criteria for the Treatment of Acute Cholecystitis.

The Tokyo Guidelines 2018 (TG18) were developed to aid diagnosis and treatment for acute cholecystitis. The benefits of being treated in an acute general surgical unit (AGSU) include earlier diagnosis and treatment. This study aims to define the usefulness of TG18 before and after the introduction of AGSU. Patients who underwent cholecystectomy at Northern Health were audited retrospectively and assessed for TG18 diagnostic criteria and outcomes between 1 February 2012 and 1 February 2014 (one-year pre- and post-AGSU). Five hundred and eighty-seven patients underwent emergency cholecystectomy with 203 (34.6%) patients having a suspected diagnosis, and 234 (39.9%) patients with a definitive diagnosis of acute cholecystitis using TG18 diagnostic criteria. After the introduction of AGSU, time from imaging to operation improved from 2.5 to 1.7days (p = 0.012). There were more operations occurring during in-hours following AGSU implementation (75.8% vs. 62.7%, p < 0.001). Maximum pre-operative CRP of >26.6mg/L had a higher likelihood of Clavien-Dindo complication grade 3 or 4 (OR 3.86, 95%CI 1.18-12.63, p = 0.027) compared with TG18 definitive diagnosis criteria (OR 1.50, 95%CI 0.46-4.91, p = 0.501). Surprisingly, there was a trend towards higher complications and readmissions for patients operated within 24h, although this trend was not significant. Patients with suspected acute cholecystitis should be stratified clinically and with CRP in an AGSU with TG18 adding little value in a busy metropolitan unit.

General Surgeons Australia's 12-point plan for emergency general surgery.

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.

Acute surgical unit improves outcomes in appendicectomy.

Few large Australian studies have explored the impact of acute surgical unit (ASU) model in appendicitis. An ASU model commenced practice at our institution on 1 August 2012. In this retrospective cohort study, patients undergoing appendicectomy 2.5 years before (Traditional group) or after (ASU group) this date were compared. Primary outcomes were median length of stay, median time from emergency department referral to theatre start and proportion of cases performed in-hours. Secondary outcomes were rates of complications, open appendicectomy, consultant scrubbed for procedure, intensive care unit admission and re-presentation to emergency department within 30 days. After removing those with incomplete data, 1214 patients were enrolled; 465 in the Traditional group and 749 in the ASU group. There were no significant baseline differences between groups. Compared with the Traditional group, ASU patients had similar length of stay (1.81 versus 1.81 days; P = 0.54) and time to theatre (0.59 versus 0.56 days; P = 0.14), but a greater proportion of in-hours operation (72% versus 79%; P = 0.014). The ASU group also experienced fewer complications (9% versus 6%; P = 0.031), fewer primary open (4% versus 1%; P < 0.0001) or conversion-to-open appendicectomies (6% versus 2%; P < 0.0005) and had superior rates of consultant scrubbed in theatre (21% versus 56%; P < 0.00001). Rates of intensive care unit admission (1% versus 1%; P = 0.72) and re-presentation were unchanged (5% versus 5%; P = 0.46). In our institution, the introduction of an ASU model was associated with more in-hours operations and safer care for patients undergoing appendicectomy.

AB195. 172. Implementing direct general practitioner referral pathways to the acute surgical assessment unit in Galway University Hospital

Background: The Acute Surgical Assessment Unit was established in Galway University Hospital in November 2017. Throughout its first year, referrals were made by Emergency department triage to the unit. In October, we introduced a direct general practitioner referral pathway, allowing surgical patients to be admitted to the surgical assessment unit directly for surgical assessment.

AB196. 179. Acute surgical assessment unit—the evolving pathway for general surgical patients

Background: Ireland has followed in the footsteps of Australia and the UK with the introduction of surgical assessment units. This year Galway University Hospital acute surgical assessment unit (ASAU) has successfully introduced a direct general practitioner referral pathway. This direct pathway allows senior decision makers to assess surgical patients with an acute surgical issue rapidly from their onset of symptoms. This efficient pathway aims to reduce unnecessary surgical admissions and ensure patients with an acute surgical issue do not experience unnecessary delays in the emergency department.

AB147. 178. Radiology support is a vital component of an efficient and effective acute surgical assessment unit

AB147. 178. Radiology support is a vital component of an efficient and effective acute surgical assessment unit

Logistical factors associated with adverse outcomes following emergency surgery in an acute care surgical unit.

The Acute Care Surgical Unit at Groote Schuur Hospital was established in 2010 and is the first of its kind in Africa. The aim of this study was to describe the outcomes of emergency surgical cases, as well as determine the logistical factors associated with adverse outcomes following surgery within the unit. This study was a retrospective audit which reviewed the folders of adult patients who underwent an emergency surgical procedure from July 2016 to July 2017. The primary outcome was a major adverse event (AE) which was defined by a Clavien-Dindo score of 3-5. A number of logistical factors related to patient admission and operation were evaluated for association with outcomes. A total of 271 patients were included with a mean age of 47 years, with 48% females and 52% males. A major AE was recorded for 13% of patients. The following factors were found to be predictive of a major AE: referral from outside the hospital, urgent booking colour code, reoperation, and consultant most senior surgeon present during procedure. Patient admission/surgery performed outside of normal working hours, being booked for surgery on admission, as well as delay to surgery beyond colour code were not associated with a major AE. Apart from the traditional clinical parameters, factors related to perioperative logistics may contribute to the risk of a major AE after emergency surgery and should be considered for inclusion in more comprehensive predictive models for adverse outcomes within an acute care surgery unit.

Emergency general surgery models in Australia: A cross-sectional study

Objective Emergency general surgery (EGS) patients experience superior outcomes when cared for within an acute surgical unit (ASU) model. EGS structures in most Australian hospitals remain unknown. This study aimed to describe the national spectrum of EGS models. Methods A cross-sectional study was performed of all Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). The primary outcome was the incidence of each EGS model. Secondary outcomes were the relationship of the EGS model to objective hospital variables, and qualitative reasons for the choice of model. Results Of the 120 eligible hospitals, 119 (99%) participated. Sixty-four hospitals reported using an ASU (28%) or hybrid EGS model (26%), whereas the remaining 55 (46%) used a traditional model. ASU implementation was significantly more common among hospitals of greater peer group, bed number, surgeon pool and trauma service sophistication. Leading drivers for ASU commencement were aims to improve patient care and decrease after-hours operating, whereas common barriers against uptake were insufficient EGS patient load or surgeon on-call pool. Conclusions ASU or hybrid models of care may be more widespread than currently reported. The introduction of such structures is heavily dependent on hospital and staff size, trauma subspecialisation and EGS patient throughput. What is known about the topic? Traditionally, general surgical staff were rostered to elective operating and clinic duties, with emergency patients managed on an ad hoc basis. An ASU model, with a surgeon dedicated to EGS patients, has been associated with superior outcomes. However, the Australian uptake of this model is unknown. What does this paper add? This study enrolled 119 of 120 (99%) Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). Uptake of the ASU or hybrid model was more widespread than expected, existing in 64 of 119 (54%) centres. Factors for and against ASU implementation were also assessed. What are the implications for practitioners? Hospitals considering implementing an ASU or hybrid model will be reassured by the common reports of improved patient outcomes and decreased after-hours operating. However, potential hospitals must assess the suitability of the ASU model to their surgeon pool and EGS patient load.

AB100. 17. Patient experience in a surgical assessment unit following a closed loop audit using a Kaizen Lean system

Background: The acute surgical assessment unit (ASAU) in University Hospital Limerick (UHL) has provided a solution to overcrowding and long waiting times since centralization of emergency services to UHL. Recognizing the importance of its evolving role, the ASAU in UHL has recently undergone a major revamp to ease the pressure in the overcrowded emergency department (ED). This included a new purpose built state of art building and equipment, improved staffing levels and use of a Kaizen Lean system to identify key area of delays and inefficiency with subsequent implementation of suggestions derived after Kaizen Lean. The aim of this study was to analyse patient satisfaction response rates with the ASAU prior to and following Kaizen Lean implementation and change to a new custom made building.

AB099. 16. Clinical effectiveness of dedicated ultrasound slots in a surgical assessment unit

Background: The bed crisis and resource limitations continue to plague the Health Service Executive, with surgical patients being admitted for next day radiologic investigations. Ultrasound scan (USS) is a cheap and non-invasive modality for assessing acute surgical presentations. The acute surgical assessment unit (ASAU) in Limerick has two dedicated USS slots daily. The aim of the current study was to investigate the clinical impact on patient care and the cost-effectiveness of such an ASAU USS access.

Impact of an acute surgical unit on outcomes in acute cholecystitis

The acute surgical unit (ASU) model has been associated with improved outcomes for emergency general surgical patients. Few Australasian studies have investigated patients with cholecystitis and none from South Australia. A retrospective cohort study compared patients admitted to our institution with acute cholecystitis during the 2 years before (traditional period) and after (ASU period) introduction of an ASU on 1 August 2012. Primary outcomes were length of stay, rates of definitive surgery on index admission, time to definitive surgery and proportion of cases performed in-hours. Secondary outcomes were time from emergency department referral to admission, time from radiologically confirmed diagnosis to theatre start, rates of conversion to open cholecystectomy, complications and cholelithiasis-related representations while awaiting definitive procedure. A total of 319 patients met the inclusion criteria; 172 and 147 pre- and post-ASU introduction, respectively. Compared with the traditional period, ASU patients had shorter length of stay (3.80 versus 2.83 days, P < 0.0001), higher rates of surgery on index admission (70.9% versus 95.3%, P < 0.0001), shorter time to definitive surgery (28.1 versus 22.1 days, P < 0.001), lower rates of conversion to open cholecystectomy (18.0% versus 7.1%, P = 0.007) and fewer complications (24.4% versus 6.1%, P < 0.0001). Other outcomes were not significantly different. Introduction of an ASU was associated with superior outcomes amongst patients admitted with acute cholecystitis. These findings extend the literature in support of the current model of care.

Improving Venous Thromboembolism Prophylaxis Administration in an Acute Surgical Unit.

Venous thromboembolism (VTE) prophylaxis regimes frequently have a wide variation in application. Nepean acute surgical unit was established in 2006 as a novel model for emergency surgical care. As part of the model's rollout, there were several areas of clinical management targeted for improvement, one being VTE prophylaxis compliance. It was decided all patients older than 18 years treated for a variety of acute surgical conditions within the acute surgical unit should be administered routine VTE prophylaxis with heparin and compression stockings. A novel multifaceted intervention was implemented at the time to achieve this goal. The primary aim of this study was to determine VTE prophylaxis administration rates before and after this intervention. A before-after study conducted as a retrospective review of medical records of all patients 18 years or older, having an appendicectomy in 3 periods: Before acute surgical unit (ASU) (November 2004 to October 2006), Early ASU (November 2006 to October 2008), and Established ASU (January 2012 to December 2013). Outcomes were mechanical and pharmacological VTE prophylaxis administration rates for each group. There were 1149 patients included in the study: Before ASU, 167; Early ASU, 375; and Established ASU, 607. There was a significant stepwise increase in parmacological VTE prophylaxis administration: Before ASU, 54.5%; Early ASU, 74.7%; and Established ASU, 96.9% (Before versus Early: odds ratio [OR], 2.46; 95% confidence interval [CI], 1.68-3.61; P < 0.001; Early versus Established: OR, 10.500; 95% CI, 6.29-17.53; P < 0.001). Mechanical VTE prophylaxis was significantly increased in the established group (Before versus Established: OR, 47.18; 95% CI, 25.61-86.91; P < 0.001). There was a significant increase in VTE prophylaxis administration after the implementation of our multifaceted intervention. Allocating a responsible provider dedicated to VTE prophylaxis prescription and compliance checking was a key component to this intervention.

Management of acute appendicitis in an acute surgical unit: a cost analysis.

The acute surgical unit (ASU) model of acute general surgery care offers efficient patient assessment, improved clinical outcomes and has been demonstrated to be cost-efficient. Despite this, the management of acute appendicitis in our ASU was found to be highly cost-negative. This study sought to identify the drivers of increased cost. A retrospective cost analysis of all patients with uncomplicated acute appendicitis in 2016 was undertaken to investigate the drivers of increased cost. The patient-level costing approach was used to assign cost to patients. The ASU management of uncomplicated appendicitis was found to have made a net loss of $625 000 in 2016. This study identified that the three largest cost drivers in appendicitis care were hospital overheads, bed day length of admission cost and operating theatre costs. Radiology, pathology and pharmacy costs did not affect total cost significantly. Two key targets for improvement were identified. First, reduced theatre turnaround times will allow more efficient theatre utilization. Second, improved after-hours and weekend theatre availability will reduce preoperative waiting time-related cost.