Emergency General Surgery Admissions Research Articles

HPB SO75 - Burden and Pattern of Gallstone-Related Acute Surgical Admissions

Abstract Background Gallstone disease accounts for nearly one-third of emergency general surgery admissions, with a considerable number resulting from recurrent episodes. Laparoscopic cholecystectomy (LC) is the only definitive treatment for gallstones. This study aimed to examine the burden and patterns of acute biliary admissions. Method This prospective cohort study was conducted over a continuous 12-week period in 2022 within a single surgical unit, focusing on all gallstone-related admissions. The total number of admissions for various surgical pathologies was documented, and the proportion due to biliary disease was determined. The analysis encompassed patient demographics, reasons for biliary admission, prior gallstone history, and any planned laparoscopic cholecystectomies (LC). Results There were 532 acute admissions, 98 (18.4%) were gallstones related. Median age was 62 years (IQR 47-72) and 58 (59.2%) were female. 40 (40.8%) had acute cholecystitis, 24 (24.5%) had gallstone pancreatitis, 16 (16.3%) had bile duct stones, 10 (10.2%) had biliary colic and 8 (8.2%) had ascending cholangitis. 43 (43.9%) patients were known to have gallstones and 26 (26.5%) patients had prior admission related to gallstones. 35.7% patients had outpatient LC, 23.5% had no documentation, 19.4% had inpatient LC, 18.4% were not fit candidates and 3.1% patients declined LC. Median total length of stay was 6 days (IQR 4-11). Conclusion In our study, the rate of biliary-related admissions was lower than previously reported in the literature. This reduction may be attributed to our semi-aggressive management approach for gallstone disease. To further improve patient outcomes, we suggest implementing more aggressive management strategies for gallstones during the initial admission for patients who are deemed fit for surgery. Such an approach could potentially reduce the recurrence of biliary admissions and enhance overall treatment efficacy.

EGS SO01 - A retrospective study on understanding the dangers of delaying emergency laparoscopic cholecystectomies in patients with acute cholecystitis

Abstract Background Gallstone related diseases account for approximately one-third of emergency general surgery admissions and referrals. Acute cholecystitis (AC), a major complication of gallstones, is typically treated with laparoscopic cholecystectomies (LC), the gold standard for treating symptomatic gallstone disease. According to NICE guidelines patients with AC should preferably undergo a LC within 72 hours. Similarly, SAGES recommends that patients who can tolerate the procedure should have a LC within 24-72 hours of diagnosis. This study aimed to determine if surgical outcomes differ among patients managed within 24 hours, between 25-72 hours, and more than 72 hours from onset of symptoms. Method This retrospective analysis evaluates wait times between onset of symptoms and surgery, as well as subsequent surgical outcomes for patients booked for emergency LC over a twelve-month period from September 2022 to September 2023. The data assessed included demographics, indications, imaging results, alkaline phosphate (ALP) levels, alanine transaminase (ALT) levels, total bilirubin levels, C-reactive protein (CRP) levels, white cell count levels, american society of anaesthesiologists (ASA) grade, type of intraoperative complications, time of day operated, length of hospital stay, duration of symptoms prior to decision for surgery and wait until surgery. This data was compared against NICE and SAGES standards. Results Sixty-one patients underwent emergency LC in the twelve-month period reviewed, mean age was 49.7 years. The sample was approximately 70% (n=43) female and 28% (n=17) male. 62% (n=38) of patients were booked for a LC within 72 hours of symptom onset. 5% (n=3) of patients had their surgery within 24 hours of presenting to hospital with symptoms, 41% (n=25) had their surgery within 24-72 hours and 54% (n=33) waited more than 72 hours for their LC. 84% (n=51) of the total patients had no adverse intraoperative findings. The 16% (n=10) patients who had complications were part of all three groups. Conclusion This study found that 46% of the patients presenting with symptoms of AC undergo emergency LC within 72 hours as per NICE and SAGES guidelines. Intraoperative complications were found in all groups of patients, waiting from 0 to 72 hours for their surgery. 80% of the complications seen were in patients waiting more than 24 hours for their LC. Increasing local awareness on the importance of not delaying emergency LC by creating pathways, such as dedicated LC lists, to allow same-admission LC will enable us to adhere more closely to current guidelines and reduce morbidity from gallstone disease.

Primary care follow-up improves outcomes in older adults following emergency general surgery admission

BACKGROUND While preoperative optimization improves outcomes for older adults undergoing major elective surgery, no such optimization is possible in the emergent setting. Surgeons must identify postoperative interventions to improve outcomes among older emergency general surgery (EGS) patients. The objective of this cohort study was to examine the association between early follow-up with a primary care physician (PCP) and the risk of nursing home acceptance or death in the year following EGS admission among older adults. METHODS Using population-based administrative health data in Ontario, Canada (2006–2016), we followed all older adults (65 years or older) for 1 year after hospital admission for EGS conditions. A multivariable Cox model was used to identify the association between early postdischarge follow-up with a patient's PCP and the time to nursing home acceptance or death while adjusting for confounders. RESULTS Among 76,568 older EGS patients, 32,087 (41.9%) were seen by their usual PCP within 14 days of discharge, and 9,571 (12.5%) were accepted to a nursing home or died within 1 year. Primary care physician follow-up was associated with a 13% reduced risk of nursing home acceptance or death compared with no follow-up (hazard ratio 0.87; 95% confidence interval 0.84–0.91). This effect was consistent across age and frailty strata, patients managed operatively and nonoperatively, and patients who had both high and low baseline continuity of care with their PCP. CONCLUSION Early follow-up with a familiar PCP was associated with a reduced risk of nursing home acceptance or death among older adults following EGS admission. Structures and processes of care are needed to ensure that such follow-up is routinely arranged at discharge. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.

Robotic availability, not payor status, determines access to robotic emergency general surgery hernia repair in California and Florida.

Previous studies have demonstrated that access to robotic surgery is influenced by socioeconomic factors, including insurance status. The 2010 Affordable Care Act established an avenue for states to expand Medicaid coverage, which has increased access to surgical care for many conditions. We hypothesized that socioeconomic disparities in access to robotic repair of non-elective emergency general surgery (EGS) hernias are less prevalent in California, a Medicaid expansion state, compared to Florida, which has not adopted Medicaid expansion. The 2021 California and Florida State Inpatient Databases were used to identify all EGS admissions with an ICD-10 procedure code for ventral or inguinal hernia repair. Elective procedures and those with concurrent unrelated abdominal procedures were excluded. Patient demographics, comorbidity burden, payor status, and income quartile were abstracted. Aggregation of hospital data identified high-volume trauma, robotic, and EGS centers. There were 15,683 EGS hernia procedures of which 11% underwent robotic repair: 14% in Florida and 8% in California. On multivariable logistic regression, older age, male sex, lower income, and Medicare insurance were associated with reduced odds of robotic hernia repair in California, but not in Florida, despite an uninsured rate of 10%. The greatest predictor of robotic surgery in both states was treatment at a robotic surgery center. Overall, accounting for patient- and hospital-level factors, hernia surgeries in Florida were more likely to involve robotics (OR 1.61, CI 1.42-1.81, p < 0.001) compared to California. There were fewer disparities in access to EGS robotic hernia repairs in Florida than in California. This suggests that robotic surgery access for EGS hernia repairs is primarily determined by institutional adoption of robotic surgery, not income or payor status. Compared to California, Florida appears to have greater market penetration of robotic surgery, which has increased access to robotic EGS for all patients.

WP5.15 - A review of emergency general surgery (EGS) admissions via the direct access pathway (DAP) in a district general hospital in United Kingdom

Abstract Aims Emergency surgical presentations require urgent attention by surgeons to ensure appropriate treatment, However, increased waiting time in A&amp;E often leads to delayed diagnosis and subsequently delayed management. A direct access pathway (DAP) to Surgical Emergency Assessment Unit (SEAU) helps minimize these delays and subsequently improve patient outcome. Methods A retrospective observational study of Emergency General Surgery (EGS) admissions from May 2023 to December 2023 was performed. Structured DAP referral proforma was implemented for patients to be directly referred to SEAU from A&amp;E triage. Factors taken into consideration were - initial presentation, source of referral, time of initial assessment and patient outcome. Results A total of 265 patients were channeled through DAP referrals during the study period, of which 96.6% were appropriate referrals. The main source of the referral the A&amp;E (52.4%), while the UTC-GP and GP constituted the remaining (47.6%). The most common clinical presentations were abdominal pain (32.4%), followed by subcutaneous abscess (17.3%). The median watiting time for initial assessment by the surgical team was 60 minutes. In terms of outcomes - 15 % patients were admitted, 14.7% were discharged after intervention, 35.8 % were discharged without intervention and 28.6% were planned to return for investigations or interventions. Conclusion The DAP for EGS admissions has enabled surgical emergencies to be addressed more promptly, and thus seen to have improved patient outcome as a result of avoiding unnecessary steps and delays before being reviewed by the surgical team through A&amp;E pathway.

EP218 - A closed-loop audit on the assessment of the documentation of frailty at admission in emergency general surgery admission at a tertiary care hospital

Abstract Background NHS frailty guidelines advise that frailty score should be documented at the first time of contact for patients aged 65+ years. The Aim of this quality improvement project (QIP) was to assess the adequate documentation of frailty at the time of first encounter by the general surgery department for patients aged 65+ years. Method Data was collected for October 2022 for the first cycle and January and February 2023 for the second cycle. Data collection was done from an electronic database in the trust and patient notes maintained throughout the admission. Results 136 patients were included in the QIP for the first cycle. 3/136 (2.2%) patients had documented frailty at the first encounter. These findings were discussed in the clinical governance meeting, followed by a teaching session for the junior doctors. A specific section was added in the documentation as a reminder for the team to document the frailty upon the first encounter. 212 patients were included in the second cycle and documentation of frailty improved to 39/212 (18.4%). Conclusion There was a lack of documentation, which improved after the intervention advised by QIP. A teaching session for new junior doctors is planned at the induction session, to strengthen the importance of frailty documentation.

Outcomes of emergency general surgery admissions in patients experiencing homelessness: A matched cohort study

BackgroundHousing status impacts outcomes after elective and emergent operations but has not been well studied in the emergency general surgery population. This study investigates the impact of housing status on complications and 30-day follow-up, emergency department visits, and readmissions after emergency general surgery admission. MethodsWe conducted a retrospective matched cohort study of adult patients admitted with an emergency general surgery diagnosis at an urban, safety net hospital from 2014 to 2021. Patients were matched 1 to 2 on the basis of age, sex, Charlson Comorbidity Index, diagnosis, and operative status. The primary exposure was unhoused status. The primary outcome was in-hospital complications. Secondary outcomes included intensive care unit admission, extended length of stay, follow-up attendance, and emergency department visit or unplanned readmission within 30 days. Multivariable conditional logistic regression was used to determine the association between housing status and the outcomes of interest. ResultsThe study included 531 patients (177 unhoused, 354 housed). There were no significant differences in complications, intensive care unit admissions, or extended length of stay. Unhoused patients had lower odds of outpatient follow-up (odds ratio, 0.54; 95% confidence interval, 0.35–0.85, P = .008) and higher odds of emergency department utilization (odds ratio, 2.72; 95% confidence interval, 1.78–4.14, P < .001) and readmission (odds ratio, 1.87; 95% confidence interval, 1.09–3.19, P = .02). ConclusionCompared with housed patients, unhoused patients with emergency general surgery conditions have lower rates of outpatient follow-up and greater odds of using the emergency department and being readmitted within 30 days of discharge. This points to a need for dedicated posthospitalization care and creative methods of engaging with this population.

142 Understanding the Burden of Emergency Bariatric Surgery Admissions

Abstract Aim To quantify the incidence and resource use of bariatric surgical emergencies (BSE) in a tertiary hospital setting. Method Patients were identified prospectively for 17 weeks from the 1st March 2023. Inclusion criteria were a bariatric emergency with an admission duration exceeding 24 hours. Results Of the 471 emergency general surgery admissions, 21 (4.5%) were identified as BSE. From 63 elective bariatric procedures, 4 (6.3%) necessitated prolonged stays owing to post-operative complications. Most patients were female (23/25), with an average age of 48 years (IQR 34-55) and a pre-operative BMI averaging 39 (IQR 37-44). The typical hospital stay was 5 days (IQR 1-15), with no reported fatalities. In total 23 patients had CT scans, 7 required surgical or procedural interventions, and 5 were admitted to the ICU. Interestingly, 12 emergency admissions had no prior NHS history, and 10 had undergone their procedures in Turkey. The post-surgery admission time was notably shorter for the Turkey group [2 (1-7) weeks] compared to those treated under the NHS [86 (5-750) weeks, p=0.003]. Conclusions More than one patient per week is admitted for a BSE. These patients have substantial resource requirements and highlight the need for adequate training and preparedness to manage these emergencies.

Emergency general surgery in older adult patients: Factors associated with fragmented care

BackgroundCare fragmentation has been shown to lead to increased morbidity and mortality. We aimed to explore the factors related to care fragmentation after hospital discharge in geriatric emergency general surgery patients, as well as examine the association between care fragmentation and mortality. MethodsWe designed a retrospective study of the Nationwide Readmissions Database 2019. We included patients ≥65 years old admitted with an emergency general surgery diagnosis who were discharged alive from the index admission. The primary outcome was 90-day care fragmentation, defined as an unplanned readmission to a non-index hospital. Multivariable logistic regression was performed, adjusting for patient and hospital characteristics. ResultsA total of 447,027 older adult emergency general surgery patients were included; the main diagnostic category was colorectal (22.6%), and 78.2% of patients underwent non-operative management during the index hospitalization. By 90 days post-discharge, 189,622 (24.3%) patients had an unplanned readmission. Of those readmitted, 20.8% had care fragmentation. The median age of patients with care fragmentation was 76 years, and 53.2% were of female sex. Predictors of care fragmentation were living in rural counties (odds ratio 1.76, 95% confidence interval: 1.57–1.97), living in a low-income ZIP Code, discharge to intermediate care facility (odds ratio 1.28, 95% confidence interval: 1.22–1.33), initial non-operative management (odds ratio 1.17, 95% confidence interval: 1.12–1.23), leaving against medical advice (odds ratio 2.60, 95% confidence interval: 2.29–2.96), and discharge from private investor-owned hospitals (odds ratio 1.18, 95% confidence interval: 1.10–1.27). Care fragmentation was significantly associated with higher mortality. ConclusionThe burden of unplanned readmissions in older adult patients who survive an emergency general surgery admission is underestimated, and these patients frequently experience care fragmentation. Future directions should prioritize evaluating the impact of initiatives aimed at alleviating the incidence and complications of care fragmentation in geriatric emergency general surgery patients.

A systematic review and meta-analysis of the use of packing in the management of perianal abscesses.

Perianal abscesses are common presentations and reasons for emergency general surgery admissions. Management involves incision and drainage of the abscess and packing the cavity with internal wound dressings. This meta-analysis aimed to assess in adults if packing an abscess or leaving it unpacked leads to a significant difference in the outcomes of pain on wound dressing, time to healing, rate of fistulation and abscess recurrence. Randomised controlled trials (RCTs) with participants aged 18 years or older that compared packing of perianal abscess cavities with no packing between 2002 and 2022 were searched for in December 2022 on OVID Medline and Embase, the CENTRAL register of trials, PubMed and Google Scholar. Risk of bias was assessed using the Cochrane Risk of Bias tool. Random effects meta-analysis was conducted on the data extracted. Three RCTs involving 490 patients were analysed for the outcomes of abscess recurrence and postoperative fistula formation; the data were not adequate to assess pain on dressing and time to healing. For unpacked versus packed, the pooled relative risk of abscess recurrence was 1.57 (95% confidence interval (CI) 0.764, 3.29, p=0.219) and for fistula formation 0.686 (95% CI 0.430, 1.09, p=0.114). These results suggest there is no significant benefit to packing abscess cavities. Analysis of the outcomes suggests there is no significant difference with regards to rates of abscess recurrence or fistula formation between the packed and unpacked groups; however, appropriately powered RCTs are required in this area to provide more primary evidence to inform best practice and clinical management.

A review of emergency general surgery (EGS) admissions via the direct access pathway (DAP) in a district general hospital

Abstract Aims Patients presenting with emergency general surgical (EGS) conditions require urgent management - however, increased waiting time in A&amp;E often leads to delayed diagnosis and subsequently delayed management. Having a direct access pathway (DAP) to Surgical Emergency Assessment Unit (SEAU) helps minimize these delays - leading to better outcome in management of these patients. Methods A retrospective observational study of EGS admissions in May 2023 was performed. Structured DAP referral proforma was implemented for patients to be directly referred to SEAU from A&amp;E triage. Factors taken into consideration were - initial presentation, source of referral, time of initial assessment and patient outcome. Results A total of 188 referrals were made to SEAU, of which 46 (24.5%) were DAP referrals. The average number was 18 over weekdays and 10 over weekends - of these, 97.8% of referrals were appropriate with correctly filled out proforma, whereas 2.2% were inappropriate referrals. 33% patients were discharged, 10% were admitted, and 10% were planned to return for investigations the following day. The median waiting time for initial assessment was 1.5hours. The most common presentations were RUQ Pain, subcutaneous abscess and RLQ pain which correlated with the final diagnosis. It was also noticed that when compared with May 2022 (176patients during the same 2-week period), there was 6.8% increased referral since commencement of DAP. Conclusion The DAP for EGS admissions has been seen to have improved patient outcome as a result of avoiding unnecessary steps and delays before being reviewed by the surgical team through A&amp;E pathway.

Assessment of the documentation of frailty at admission in emergency general surgery admission at a tertiary care hospital

Abstract Background NHS frailty guidelines advise that frailty score should be documented at the first time of contact for patients aged 65+ years. The Aim of this quality improvement project (QIP) was to assess the adequate documentation of frailty at the time of first encounter by the general surgery department for patients aged 65+ years. Method Data was collected for October 2022 for the first cycle and January and February 2023 for the second cycle. Data collection was done from an electronic database in the trust and patient notes maintained throughout the admission. Results 136 patients were included in the QIP for the first cycle. 3/136 (2.2%) patients had documented frailty at the first encounter. These findings were discussed in the clinical governance meeting, followed by a teaching session for the junior doctors. A specific section was added in the documentation as a reminder for the team to document the frailty upon the first encounter. 212 patients were included in the second cycle and documentation of frailty improved to 39/212 (18.4%). Conclusion There was a lack of documentation, which improved after the intervention advised by QIP. A teaching session for new junior doctors is planned at the induction session, to strengthen the importance of frailty documentation.

Association of social determinants of health International Classification of Disease, Tenth Edition clinical modification codes with outcomes for emergency general surgery and trauma admissions

BackgroundPatients with Acute Care Surgery needs (ie, emergency general surgery diagnosis or trauma admission) are at particularly high risk for nonmedical patient-related factors that can be important drivers of healthcare outcomes. These social determinants of health are typically ascertained at the geographic area level (ie, county or neighborhood) rather than at the individual patient level. Recently, the International Classification of Diseases Tenth Revision, Tenth Edition created codes to capture health hazards related to patient socioeconomic and psychosocial circumstances. We sought to characterize the impact of these social determinants of health–related codes on perioperative outcomes among patients with acute care surgery needs. MethodsPatients diagnosed between 2017 and 2020 with acute care surgery needs (ie, emergency general surgery diagnosis or a trauma admission) were identified in the California Department of Healthcare Access and information Patient Discharge database. Data on concomitant social determinants of health–related codes (International Classification of Diseases Tenth Revision, Tenth Edition Z55-Z65), which designated health hazards related to socioeconomic and psychosocial (socioeconomic and psychosocial, respectively) circumstances, were obtained. After controlling for patient factors, including age, sex, race, payer type, and admitting hospital, the association of socioeconomic and psychosocial codes with perioperative outcomes and hospital disposition was analyzed. ResultsAmong 483,280 with an acute care surgery admission (emergency general surgery: n = 289,530, 59.9%; trauma: n = 193,705, 40.1%) mean age was 56.5 years (standard deviation: 21.5) and 271,911 (56.3%) individuals were male. Overall, 16,263 (3.4%) patients had a concomitant socioeconomic and psychosocial diagnosis code. The percentage of patients with a concurrent social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis increased throughout the study period from 2.6% in 2017 to 4.4% in 2020. Patients that were male (odds ratio 1.89; 95% confidence interval 1.82, 1.96), insured by Medicaid (odds ratio 5.43; 95% confidence interval 5.15, 5.72) or self-pay (odds ratio 3.04; 95% confidence interval 2.75, 3.36) all had higher odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. Black race did not have a significant association with an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis (odds ratio 0.99; 95% confidence interval 0.94, 1.04); however, Hispanic (odds ratio 0.44; 95% confidence interval 0.43, 0.46) and Asian (odds ratio 0.40; 95% confidence interval 0.36, 0.44) race/ethnicity was associated with a lower odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. After controlling for competing risk factors on multivariable analyses, the risk-adjusted probability of hospital postoperative death was 3.1% (95% confidence interval 2.8, 3.4) among patients with a social determinants of health diagnosis versus 5.9% (95% confidence interval 5.9, 6.0) (odds ratio 0.48; 95% confidence interval 0.44, 0.54) among patients without a social determinants of health diagnosis. Risk-adjusted complications were 26.7% (95% confidence interval 26.1, 37.3) among patients with a social determinants of health diagnosis compared with 31.9% (95% confidence interval 31.7, 32.0) (odds ratio 0.74; 95% confidence interval 0.71, 0.77) among patients without a social determinants of health diagnosis. ConclusionInternational Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code use was low, with only 3.4% of patients having documentation of a socioeconomic and psychosocial circumstance. The presence of an International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code was not associated with greater odds of complications or death; however, it was associated with longer length of stay and higher odds of being discharged to a skilled nursing facility.

Primary Care Physician Follow-Up and 30-Day Readmission After Emergency General Surgery Admissions

The benefit of primary care physician (PCP) follow-up as a potential means to reduce readmissions in hospitalized patients has been found in other medical conditions and among patients receiving high-risk surgery. However, little is known about the implications of PCP follow-up for patients with an emergency general surgery (EGS) condition. To evaluate the association between PCP follow-up and 30-day readmission rates after hospital discharge for an EGS condition. This cohort study used data from the Centers for Medicare & Medicaid Services Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files for beneficiaries aged 66 years or older who were hospitalized with an EGS condition that was managed operatively or nonoperatively between September 1, 2016, and November 30, 2018. Eligible patients were enrolled in Medicare fee-for-service, admitted through the emergency department with a primary diagnosis of an EGS condition, and received a general surgery consultation during the admission. Data were analyzed between July 11, 2022, and June 5, 2023. Follow-up with a PCP within 30 days after hospital discharge for the index admission. The primary outcome was readmission within 30 days after discharge for the index admission. An inverse probability weighted regression model was used to estimate the risk-adjusted association of PCP follow-up with 30-day readmission. The secondary outcome was readmission within 30 days after discharge stratified by treatment type (operative vs nonoperative treatment) during their index admission. The study included 345 360 Medicare beneficiaries (mean [SD] age, 74.4 [12.0] years; 187 804 females [54.4%]) hospitalized with an EGS condition. Of these, 156 820 patients (45.4%) had a follow-up PCP visit, 108 544 (31.4%) received operative treatment during their index admission, and 236 816 (68.6%) received nonoperative treatment. Overall, 58 253 of 332 874 patients (17.5%) were readmitted within 30 days after discharge for the index admission. After risk adjustment and propensity weighting, patients who had PCP follow-up had 67% lower odds of readmission (adjusted odds ratio [AOR], 0.33; 95% CI, 0.31-0.36) compared with patients without PCP follow-up. After stratifying by treatment type, patients who were treated operatively during their index admission and had subsequent PCP follow-up within 30 days after discharge had 79% reduced odds of readmission (AOR, 0.21; 95% CI, 0.18-0.25); a similar association was seen among patients who were treated nonoperatively (AOR, 0.36; 95% CI, 0.34-0.39). Infectious conditions, heart failure, acute kidney failure, and chronic kidney disease were among the most frequent diagnoses prompting readmission overall and among operative and nonoperative treatment groups. In this cohort study, follow-up with a PCP within 30 days after discharge for an EGS condition was associated with a significant reduction in the adjusted odds of 30-day readmission. This association was similar for patients who received operative care or nonoperative care during their index admission. In patients aged 66 years or older with an EGS condition, primary care coordination after discharge may be an important tool to reduce readmissions.

1078 Assessing the Compliance &amp; Adherence to the Emergency General Surgery Admission Proforma via ‘Take 10’ Principles - a Complete Clinical Audit

Abstract Aim To assess the adherence and compliance to the emergency general surgery admission proforma, based on the ‘Take 10’ principles which includeObservationsExaminationsImpressionInvestigationsAntibioticsIV FluidsVTE RiskNutritional AssessmentEstimated Length of StayCeiling of Care Method Retrospective review of the admission proformas of 20 random patients was done - without prompting the admitting team to strictly comply to the ‘Take 10” principles. Education was provided to the next surgical on-call team, who were encouraged to fill out the proforma and carry out the post-take ward round using ‘Take 10’ principles. A relook retrospective review was carried out on a subsequent 20 random patients after 4 weeks. The results from both weeks were compared. Results Percentage adherence Observations:25% in 1st week and 95 % in 2nd week Examinations:100% in 1st week and 100 % in 2nd week Impression:100% in 1st week and 100 % in 2nd week Investigations:95% in 1st week and 100 % in 2nd week Antibiotics:63% in 1st week and 90 % in 2nd week IV Fluids:25% in 1st week and 95 % in 2nd week VTE Risk:45% in 1st week and 100 % in 2nd week Nutritional Assessment:48% in 1st week and 100 % in 2nd week Estimated Length of Stay:10% in 1st week and 85 % in 2nd week Ceiling of Care:12% in 1st week and 78 % in 2nd week Conclusions The implementation of the Take 10 checklist during the post take surgical ward round, resulted in improved documentation on the emergency general surgery admission proforma.

SP9.4 Improving time to initial consultant review for emergency general surgery admissions at a major trauma centre

Abstract NHS England’s Seven Day Services Clinical Standards and NCEPOD Guidance recommend 100% of emergency admissions to hospital should receive an initial consultant review within 14-hours of hospital admission. An audit of time for initial consultant review for emergency general surgery (EGS) admissions at a Major Trauma Centre revealed only 75% of patients were reviewed by a consultant surgeon within the 14-hour target, with longest time to review 20 hours and 56 minutes. Aim To assess and improve compliance of time to initial consultant review for EGS admissions with the recommended standard by implementing twice daily versus once daily post take ward rounds (PTWR). Standard 100% of EGS admissions should have a consultant review within 14-hours of hospital admission. Methods Retrospective review of admission data and progress notes on the electronic medical record for all patients admitted under EGS from 00:00 Monday 26/9/2022 – 23:59 Friday 30/9/22 (identified from general surgery take list) three weeks post intervention. Data inputted onto a single audit tool and analyzed in Microsoft Excel in comparison to initial audit data (one month prior to intervention). Results Twice daily compared to once daily PTWRs improved compliance with the audit standard by 25%; 100% of patients reviewed within 14-hours. Longest time for initial consultant review decreased by 11hr 04min (20hr 56min to 09hr 52min). Number of patients reviewed in the emergency department by a consultant increased from 25% to 50%. Conclusions 100% of EGS patients can receive an initial consultant review in line with the nationally recommended timeframe with the introduction of twice daily versus once daily PTWRs.

84 Emergency General Surgery medical records standards at a tertiary referral hospital: Lessons learned from Royal College of Physicians

Abstract Introduction The record keeping standards published by the Royal College of Physicians (RCP) aimed to maximize patient safety, quality of care, support professional best practice and assist compliance with Information Governance and NHS Litigation Authority. We aimed to study the medical records keeping in emergency general surgery admissions at a London tertiary hospital. Methods A randomized retrospective analysis of 30 patients was performed in a period from 1st May 2022 to 1st August 2022. Results of the first cycle were presented at a local meeting, followed by action plans and recommendations. A teaching session has been delivered for junior doctors about the RCP standards and planned to be delivered every 4 months for all new staff members. A closing loop has been carried with same methodology and number of emergency surgical admissions from 1st November 2022 to 22nd of November 2022. Results Good standards of records keeping in the first cycle was reached in 8 (100%) out of the 12 RCP criteria, with multiple areas that needed improvement. In the closing loop, a significant improvement was reached: discharge letters standards with 93.3% compared to 86.7 % in the first cycle, 3.3% records contained information filled in irrelevant section compared to 20%, 10 % of the cases in the second cycle had advanced decisions documentation compared to 0% in the first cycle. Conclusions The maintenance of good medical record keeping requires regular audit and formal education of junior doctors to reach a high standard in emergency surgical admissions according to the RCP record keeping criteria.

FTP5.8 Gall bladder service developments to improve outcomes based on national guidelines

Abstract Introduction Nationally, acute gallstone disease accounts for over 1/3rd of emergency general surgery admissions and referrals. Guidelines recommend laparoscopic cholecystectomy within 1 week for acute cholecystitis, on index admission for acute gallstone pancreatitis and within 18 weeks for uncomplicated gallstone disease. Presently, NHS Trusts struggle to meet these targets due to unrelenting demand for limited resources. We present interventions to improve a laparoscopic cholecystectomy service which nearly halved the elective surgery waiting time. Method Retrospective data was collected on patients who underwent elective laparoscopic cholecystectomy at a DGH pre- and post-intervention (March-July 2021 &amp; January-April 2022). Data collected from electronic medical records included patient demographics, waiting list times, operation details and post-operative outcomes. Interventions included introduction of a boarding card which included Cholecystectomy As A Day-case (CAAD) scoring and laparoscopic cholecystectomy standard operating procedure (SOP). The SOP specified criteria for preoperative investigations, theatre list organisation, post-operative admission and high-risk patients requiring specialist surgeon input. Results Pre-intervention cycle included 82 patients, with 78 patients booked as day-case operations and 40.2% unplanned postoperative admissions rate. The post-intervention period assessed 72 patients, with 46 patients booked as day-cases and 30.6% unplanned postoperative admissions. The median day-case LOS remained at 0 days pre- and post-intervention. Median elective laparoscopic cholecystectomy waiting time significantly decreased from 140 to 75 days (p&amp;lt; 0.0001). Conclusion Our study demonstrates interventions to restructure a laparoscopic cholecystectomy service significantly shortened waiting times, with national targets of 18-week wait for uncomplicated gallstone disease surgery met. Additionally, fewer unplanned postoperative admissions allows better bed management therefore reducing disruption to elective and emergency service delivery.

Comparison of major abdominal emergency surgery outcomes across organizational models of emergency surgical care: Analysis of the UK NELA national database.

Emergency general surgery (EGS) admissions account for a large proportion of surgical care and represent the majority of surgical patients who suffer in-hospital mortality. Health care systems continue to experience growing demand for emergency services: one way in which this is being increasingly addressed is dedicated subspecialty teams for emergency surgical admissions, most commonly termed "emergency general surgery" in the United Kingdom. This study aims to understand the impact of the emergency general surgery model of care on outcomes from emergency laparotomies. Data was obtained from the National Emergency Laparotomy Audit database. Patients were dichotomized into EGS hospital or non-EGS hospital. Emergency general surgery hospital is defined as a hospital where >50% of in-hours emergency laparotomy operating is performed by an emergency general surgeon. The primary outcome was in-hospital mortality. Secondary outcomes were intensive therapy unit (ITU) length of stay and duration of hospital stay. A propensity score weighting approach was used to reduce confounding and selection bias. There were 115,509 patients from 175 hospitals included in the final analysis. The EGS hospital care group included 5,789 patients versus 109,720 patients in the non-EGS group. Following propensity score weighting, mean standardized mean difference reduced from 0.055 to <0.001. In-hospital mortality was similar (10.8% vs. 11.1%, p = 0.094), with mean length of stay (16.7 days vs. 16.1 days, p < 0.001) and ITU stay (2.8 days vs. 2.6 days, p < 0.001) persistently longer in patients treated in EGS systems. No significant association between the emergency surgery hospital model of care and in-hospital mortality in emergency laparotomy patients was seen. There is a significant association between the emergency surgery hospital model of care and an increased length of ITU stay and overall hospital stay. Further studies are required to examine the impact of changing models of EGS delivery in the United Kingdom. Prognostic and Epidemiological; Level III.

Association of Intellectual Disability with Delayed Presentation and Worse Outcomes in Emergency General Surgery.

To examine the association between intellectual disability and both severity of disease and clinical outcomes among patients presenting with common emergency general surgery (EGS) conditions. Accurate and timely diagnosis of EGS conditions is crucial for optimal management and patient outcomes. Individuals with intellectual disabilities may be at increased risk of delayed presentation and worse outcomes for EGS; however, little is known about surgical outcomes in this population. Using the 2012-2017 Nationwide Inpatient Sample, we conducted a retrospective cohort analysis of adult patients admitted for 9 common EGS conditions. We performed multivariable logistic and linear regression to examine the association between intellectual disability and the following outcomes: EGS disease severity at presentation, any surgery, complications, mortality, length of stay, discharge disposition, and inpatient costs. Analyses were adjusted for patient demographics and facility traits. Of 1,317,572 adult EGS admissions, 5,062 (0.38%) patients had a concurrent ICD-9/-10 code consistent with intellectual disability. EGS patients with intellectual disabilities had 31% higher odds of more severe disease at presentation compared with neurotypical patients (aOR 1.31; 95% CI 1.17-1.48). Intellectual disability was also associated with a higher rate of complications and mortality, longer lengths of stay, lower rate of discharge to home, and higher inpatient costs. EGS patients with intellectual disabilities are at increased risk of more severe presentation and worse outcomes. The underlying causes of delayed presentation and worse outcomes must be better characterized to address the disparities in surgical care for this often under-recognized but highly vulnerable population.