Emergency Surgical Admissions Research Articles

The effect of the SARS-CoV2 pandemic and lockdown on non-Covid ICU admissions: Experience from a South African tertiary hospital

Background. Future pandemic planning involves analysing past experiences. We compared intensive care unit (ICU) admissions during the SARS- CoV-2 pandemic (2020) with the preceding year. Objectives. To assess the SARS-CoV-2 pandemic’s effect on ICU admissions in a tertiary hospital, examining differences in patient characteristics, organ support requirements, reason for admission, mortality rates and length of ICU stay. Methods. This retrospective cohort study compared ICU patient data at a tertiary hospital during the SARS-CoV-2 pandemic (26 March 2020 to 20 September 2020) with the same period in 2019. Results. Patient admissions (p=0.39) and severity of illness (p=0.27 adults; p=0.92 paediatrics) showed no differences across the study period. Similarly, no differences were observed for underlying chronic conditions between the two years. Adult trauma admissions significantly declined, specifically those related to road traffic accidents (RR 0.63). Admissions for acute infectious conditions, including respiratory infections, sepsis, urosepsis, septic arthritis and gastroenteritis significantly declined in both adults (RR 0.50) and paediatric admissions (RR 0.25). During the lockdown period, the length of stay (LOS) decreased for adults, but mortality rates remained unchanged across the study period. The paediatric mortality rate decreased during the lockdown period (p=0.004). Conclusion. There was no reduction in SARS-CoV-2-negative ICU admissions during the 2020 lockdown period compared with the preceding year, likely due to chronic resource limitations. We found a decrease in acute trauma and acute infectious illness admissions, while acute surgical emergency admissions increased. These findings suggest that lockdown orders may have affected admission patterns, aiding in future pandemic planning.

A multicentre survey investigating the knowledge, behaviour, and attitudes of surgical healthcare professionals to frailty assessment in emergency surgery: DEFINE(surgery).

Screening for frailty in people admitted with emergency surgical pathology can initiate timely referrals to enhanced perioperative services such as intensive care and geriatric medicine. However, there has been little research exploring surgical healthcare professionals' opinions to frailty assessment, or accuracy in identification. This study aimed to assess the knowledge, behaviour, and attitudes of healthcare professionals to frailty assessment in emergency surgical admissions. We designed a cross-sectional multicentre study developed by a multiprofessional team of surgeons, geriatricians, and supported by patients. A semi-structured survey examined attitudes and behaviours. Knowledge was assessed by comparing respondents' accuracy in scoring twenty-two surgical case vignettes using the Clinical Frailty Scale. Eleven hospitals across England, Wales, and Scotland participated. Two hundred and eleven clinicians responded-20.4% junior doctors, 43.6% middle grade doctors, 24.2% senior doctors, 11.4% nurses and physician associates. Respondents strongly supported perioperative frailty assessment. Most were already assessing for frailty, although frequently not using a standardised tool. There was a strong call for more frailty education. Participants scored 2175 vignettes with 55.4% accurately meeting the gold standard; accuracy improved to 87.3% when categorised into "not frail/mildly frail/severely frail" and 94% when dichotomised to "not frail/frail". Frailty assessment is well supported by healthcare professionals working in surgery. However, standardised tools are not routinely being used, and only half of respondents could accurately identify frailty. Better education around frailty assessment is needed for healthcare professionals working in surgery to improve perioperative pathway for people living with frailty.

Ileo-ileal knot causing acute gangrenous small bowel obstruction: a case report

BackgroundIleo-ileal knotting is a very rare cause of small bowel obstruction, and only a few reports have been published. Small bowel obstruction (SBO) is one of the most common emergency surgical conditions that require urgent evaluation and treatment and is one of the leading causes of emergency surgical admission. There are many causes of SBO that are known in general surgical practice, and these causes are different in the developing and developed worlds.Clinical presentationIn this article, we present a case of acute gangrenous SBO secondary to ileo-ileal knotting in a 37-year-old Ethiopian female patient after she presented with severe abdominal cramp, vomiting, and abdominal distension of 4 hours duration. The patient was operated on intraoperatively; she had gangrenous small bowel obstruction caused by ileo-ileal knotting. Later, the patient was discharged and improved after 12 days of hospital stay.ConclusionIleo-ileal knotting should always be considered in the differential diagnosis of acute small-bowel obstruction. The diagnostic difficulty and the need for urgent treatment of this condition to yield optimal results are discussed.

Audit of Emergency Laparoscopic Cholecystectomy in a District General Hospital.

Introduction Acute gallstone diseases are common surgical emergencies, accounting for approximately one-third of emergency surgical admissions. Laparoscopic cholecystectomy is thestandard choice of treatment for gallstone diseases and is currently one of the most commonly performed surgical procedures in the United Kingdom.Majority of these procedures are carried out as elective cases. National Institute of Clinical Excellence (NICE) guidelines and other upper gastrointestinal surgery specialty bodies encourage early emergency surgery inacute symptomatic gallstone disease. Weassessed emergency laparoscopic cholecystectomiesperformed at Birmingham Heartlands Hospital, United Kingdom andcompared the practice against NICE and British Benign Upper Gastrointestinal Surgery Society (BBUGSS) recommendations. Methods This is a snapshot retrospective audit, assessing emergency laparoscopic cholecystectomy practice over a nine-month periodfrom November 2022 to July 2023.Variables assessed were demographics, duration of symptoms prior to surgery, imaging modality, indications, C-reactive protein (CRP) levels, operative difficulty, intraoperative and postoperative complications, length of hospital stay and readmission rates. These variables were compared against both NICE and BBUGSS standards.We aimed to establish baseline data to encourage emergency laparoscopic cholecystectomies in our hospital and reduce repeated hospital visits for patients with acute gallbladder disease. Results Forty-eight patients had emergency laparoscopic cholecystectomy in the period reviewed, mean age was 44.3 years and females accounted for approximately 71% (n=34) of the group. 66.7% (n=32) of patients had their surgery within seven days of diagnosiswith acute gallstone disease; 50% (n=24)of patients had no adverse intraoperative event.No patient had biliary tract injury despite a high number of difficult cases. Overall there was no correlation between duration before surgery and intraoperative difficulty or readmission rates.

Offering Surgical Definitive Options For Sigmoid Volvulus: Lessons From WSES (World Society of Emergency Surgery) Consensus Guidelines

Abstract Aim This study evaluates the quality of care provided to patients with sigmoid volvulus and assess compliance with the World Society of Emergency Surgery (WSES) Consensus Guidelines regarding offering definitive surgical intervention. Methods All emergency surgical admissions involving individuals aged 65 or older, diagnosed with sigmoid volvulus between 2021 and 2023, were retrospectively included. The evaluation was conducted in conjunction with five critical WSES recommendations, encompassing the assessment strategy and diagnostic imaging for sigmoid volvulus, initial flexible endoscopy, and the decision-making process for urgent or elective sigmoid resection in all initial presentations. Adherence to these standards was assessed in each domain and subsequently categorized as Red (Urgent Attention Needed), Amber (Room for Improvement), or Green (Satisfactory Compliance). Results The study included a total of 20 patients. Compliance with the recommendation to offer sigmoid colectomy for the prevention of recurrent volvulus after successful endoscopic decompression was found to be in the Red category, scoring at 25%. In contrast, the remaining recommendations demonstrated satisfactory levels of compliance. Conclusion 25% of our patients have not been offered the option of definitive surgical resection, highlighting an area for urgent need of attention. Given that the recurrence rate of sigmoid volvulus after endoscopic detorsion and conservative management ranges from 45% to 71%, and offering sigmoid colectomy to prevent recurrent volvulus is crucial, even during the index admission. In cases where frailty is identified, there should be documented consideration of best interest during the planning of definitive care. We envisage a better compliance to WSES recommendations.

Embedding a Novel Screening Programme for Sexually Transmitted Infections Within an Ambulatory Emergency Surgical Admissions Unit: An Observational Cohort Study

Abstract Aims To establish a sexually transmitted infection (STI) screening programme for females presenting to an Emergency Ambulatory Surgical Clinic (ASC), and to analyse incidence and prevalence of STIs as an underlying cause for their abdominal pain. Methods Observational cohort study in ASC of a tertiary hospital. Between December 2021 to December 2022, females aged 18-44 years presenting with abdominal pain were offered self-collected vulvovaginal swabs for chlamydia and gonorrhoea as part of a new standardised diagnostic pathway. Positive results were referred to local sexual health services for treatment and contact tracing. Main outcome measures included number of patients consenting to the screening programme and number of positive swab results. Results The cohort comprised 297 eligible patients; 259 with 20 patients declining testing and 18 samples rejected. A total of 5.4% of swabs were positive (2 gonorrhoea, 12 chlamydia) with mean age of 24.5. All positive patients presented with lower abdominal pain and of these, only 25% had a documented sexual history during assessment. 7 had further imaging with 4 results diagnosing pelvic inflammatory disease (PID). 4 patients were treated for PID empirically. Remaining patients were treated for non-specific pain or unrelated pathology. Conclusions Undiagnosed STIs are prevalent, and have known fertility and public health risks. Young females with lower abdominal pain provide an opportunistic and arguably necessary screening cohort in ASC with good uptake of self-testing. Results demonstrate high incidence of positive tests, suggesting that inclusion of sexual history during assessment is vital to identify those with highest STI risk.

690 Quality Improvement Project: Improving Engagement with Smoking Cessation Services Among Emergency Surgical Admissions

Abstract Aim Smoking status has a significant impact on surgical patient outcomes, with significantly increased rates of intra- and post-operative complications. Within Liverpool University Hospitals NHS Foundation Trust (LUHFT), the CURE team is a dedicated smoking cessation service that uses an electronic proforma to identify smokers and offer support. We assessed smoking cessation efforts among emergency surgical admissions pre- and post-teaching intervention. Method Two rounds of audit were completed: a baseline audit of emergency surgical admissions from 01/01/21 to 31/01/21(n = 202); and a reaudit of emergency surgical admissions from 01/11/22 to 30/11/22 (n = 163), following a structured teaching session on smoking cessation, delivered to incoming doctors in August 2022. We assessed documentation of smoking status within patient notes, completion of the smoking status proforma, prescription of nicotine replacement therapy (NRT), and assessment/follow up from CURE. Results Following intervention, smoking status documentation improved from 83% (n = 166) to 96% (n = 157), and proforma completion from 55% (n = 112) to 91% (n = 148). Among documented smokers (cycle 1 n = 49; cycle 2 n = 47), NRT prescription improved from 29% to 40%, and CURE involvement increased from 31% to 64%. Overall, following intervention, 21% of smokers accepted ongoing support from CURE during and post-admission, compared to 10% at baseline. Conclusions Use of electronic smoking status proforma and a dedicated inpatient smoking cessation team has high rates of engagement among emergency surgical inpatients. The use of structured teaching sessions to highlight the importance of smoking cessation among these patients has led to improved rates of smoking cessation support, benefiting surgical outcomes.

1088 Acute Pancreatitis: ‘Treat the Cause’-in Compliance with NCEPOD Recommendations

Abstract Aim The objective of this study was to facilitate in identifying remediable factors in the quality of care provided to patients being treated for acute pancreatitis and assess compliance to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) guidelines. Method All emergency surgical admissions for patients aged 16 or older, diagnosed with acute pancreatitis at the period between August and October 2021 were included. A retrospective analysis in juxtaposition with 8 cardinal NCEPOD recommendations: management of co-morbidity & involvement of relevant specialists, adherence to antibiotic policies, assessment of risk of malnutrition, exclusion of gallstones in all index presentations, early surgical intervention, alcohol liaison support, further investigation - MRCP / ERCP and retrospective morbidity & mortality discussions. Each of the domains were scored based on adherence to the above standards, and subsequently coded as Red–Needing Urgent Attention, Amber–Scope for Improvement and Green–Satisfactory Compliance. Results A total of 79 patients were included in this study. Compliance towards the recommendation of routine nutritional assessment of patients was found to be in the RED category, scoring 23.7%. Management of medical co-morbidity & inclusion of specialists, early surgical intervention and alcohol liaison support were all found to be in the AMBER category, scoring 44.8%, 28.0% and 57.1% respectively. The rest of the recommendations showed satisfactory levels of compliance. Conclusions Many patients did not receive adequate nutritional assessment. The RED and AMBER areas will need urgent attention. To minimise the risks of severe morbidity and mortality from acute pancreatitis, we envisage a better compliance to NCEPOD recommendations.

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.

WTP4.12 Treating the cause of Acute Pancreatitis: lessons from NCEPOD guidelines

Abstract Aim The objective of this study was to facilitate in identifying remediable factors in the quality of care provided to patients being treated for acute pancreatitis and assess compliance to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) guidelines. Method All emergency surgical admissions for patients aged 16 or older, diagnosed with acute pancreatitis at the period between August and October 2021 were included. A retrospective analysis in juxtaposition with 8 cardinal NCEPOD recommendations: management of co-morbidity & involvement of relevant specialists, adherence to antibiotic policies, assessment of risk of malnutrition, exclusion of gallstones in all index presentations, early surgical intervention, alcohol liaison support, further investigation - MRCP / ERCP and retrospective morbidity & mortality discussions. Each of the domains were scored based on adherence to the above standards, and subsequently coded as Red–Needing Urgent Attention, Amber–Scope for Improvement and Green–Satisfactory Compliance. Results A total of 79 patients were included in this study. Compliance towards the recommendation of routine nutritional assessment of patients was found to be in the RED category, scoring 23.7%. Management of medical co-morbidity & inclusion of specialists, early surgical intervention and alcohol liaison support were all found to be in the AMBER category, scoring 44.8%, 28.0% and 57.1% respectively. The rest of the recommendations showed satisfactory levels of compliance. Conclusion Many patients did not receive adequate nutritional assessment. The RED and AMBER areas will need urgent attention. To minimise the risks of severe morbidity and mortality from acute pancreatitis, we envisage a better compliance to NCEPOD recommendations.

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.

The Impact of Homelessness, Substance Use, and Mental Illness on Surgical Inpatient Outcomes in Australia.

This study investigated inpatient surgical outcomes for people experiencing homelessness (PEH) in Australia. Retrospective administrative health data of emergency surgical admissions from a single center over five years, 2015 to 2020, was included. Independent associations between factors and outcomes were analyzed with binary logistic and log-linear regression. Of 11 229 admissions, 2% were experiencing homelessness. People experiencing homelessness were on average younger (49 vs 56 years), more likely to be males than females (77% vs 61%), suffer mental illness (10% vs 2%), and substance use disorders (54% vs 10%). People experiencing homelessness were not more likely to suffer surgical complications. However, male sex, older age, mental illness, and substance use were risk factors for poor surgical outcomes. Homelessness predicted greater odds of discharge against medical advice (4.3 times) and longer length of stay (1.25 times). These results highlighted the need for health interventions simultaneously addressing physical, mental health, and substance use issues in the care of PEH.

Perceptions and practices surrounding the perioperative management of frail emergency surgery patients: a WSES-endorsed cross-sectional qualitative survey

BackgroundFrailty is associated with poor post-operative outcomes in emergency surgical patients. Shared multidisciplinary models have been developed to provide a holistic, reactive model of care to improve outcomes for older people living with frailty. We aimed to describe current perioperative practices, and surgeons’ awareness and perception of perioperative frailty management, and barriers to its implementation.MethodsA qualitative cross-sectional survey was sent via the World Society of Emergency Surgery e-letter to their members. Responses were analysed using descriptive statistics and reported by themes: risk scoring systems, frailty awareness and assessment and barriers to implementation.ResultOf 168/1000 respondents, 38% were aware of the terms “Perioperative medicine for older people undergoing surgery” (POPS) and Comprehensive Geriatric Assessment (CGA). 66.6% of respondents assessed perioperative risk, with 45.2% using the American Society of Anaesthesiologists Physical Status Classification System (ASA-PS). 77.8% of respondents mostly agreed or agreed with the statement that they routinely conducted medical comorbidity management, and pain and falls risk assessment during emergency surgical admissions. Although 98.2% of respondents agreed that frailty was important, only 2.4% performed CGA and 1.2% used a specific frailty screening tool. Clinical frailty score was the most commonly used tool by those who did. Screening was usually conducted by surgical trainees. Key barriers included a lack of knowledge about frailty assessment, a lack of clarity on who should be responsible for frailty screening, and a lack of trained staff.ConclusionsOur study highlights the ubiquitous lack of awareness regarding frailty assessment and the POPS model of care. More training and clear guidelines on frailty scoring, alongside support by multidisciplinary teams, may reduce the burden on surgical trainees, potentially improving rates of appropriate frailty assessment and management of the frailty syndrome in emergency surgical patients.

The impact of psychiatric comorbidities on emergency general surgical patients’ outcomes

BackgroundPsychiatric disorders are increasingly prevalent. Studies have demonstrated that the presence of comorbid psychiatric conditions (CPC) is associated with a number of worsening outcomes in hospitalised patients in general. The relationship between a wide range of psychiatric comorbidities and acute surgical presentations has not been studied to date. Study designThe Hospital In-Patient Enquiry (HIPE) system and prospectively maintained eHandover were used to identify all surgical emergency admissions to Mayo University Hospital, Ireland. Patient demographics, comorbidities, primary diagnoses, length of stay (LoS), and procedures undergone were recorded over a 12-months period. Subgroup analyses examining LoS variation in surgical presentation types were performed. Results1028 admissions occurred over this one year period, amongst 995 patients, the presence of psychiatric comorbidities increased the mean LoS by 1.9 days (p = 0.002). Comorbid depression, dementia, and intellectual disability conferred a significant increase in LoS by 2.4 days, 2.8 days and 6.7 days respectively. Subgroup analysis revealed greater LoS in patients with CPC diagnosed with non-specific abdominal pain (1.4 days, p = 0.019), skin and soft tissue infections (2.5 days, p = 0.040), bowel obstruction (4.3 days, p = 0.047), and medical disorders (18.6 days, p = 0.010). No significant difference was observed in mortality and readmission rates. ConclusionPsychiatric comorbidities significantly impact length of hospital stay and discharge planning in surgical inpatients. Greater awareness of this can facilitate better care delivery for this population to reduce the LoS and subsequent economic burden on the healthcare system.

HPB P56 Outcomes of laparoscopic versus percutaneous cholecystostomy in high-risk patients with acute calculus cholecystitis

Abstract Background Around 10–15% population in the UK have gallstones. (1) Gall stone related disease account for 1/3rd of the emergency surgical admissions and referrals. (2) Acute cholecystitis, which is the inflammation of the gall bladder can develop in 1–3% of these patients. (3) Without treatment, acute cholecystitis may resolve spontaneously within 1–7 days. However, 25–30% of people will require surgery or develop complications. (4) Laparoscopic cholecystectomy is the standard technique for management of acute cholecystitis. However, in the patients who are high risk, LC can result in significant mortality and morbidity. According to the Dutch guidelines for management of Gall Bladder stones disease, high risk patients such as those with multiple comorbidities or those who present with sepsis, LC is not the best management option. (5) In such patients percutaneous cholecystostomy (PC) is sometimes accepted as a bridge to the definitive management. (6) (7) Percutaneous image guided cholecystostomy is a safe and important in such scenarios. However, in those patients who present to the hospital at occasions during which interventional radiology service is not available, laparoscopic cholecystostomy would remain a safe and efficient temporary alternative for management of acute cholecystitis not responding to medical treatment. (8) Methods A retrospective analysis of the 29 patients who were admitted in our hospital and had cholecystostomy between 2015–2021 was done. Eleven (11) patients had Laparoscopic cholecystostomy were allocated to Group A and ten 18 patients who underwent US guided cholecystostomy were assigned to Group B. The data was collected regarding the timing of procedure (Day/Night), 30 days and 1 year mortality, duration of hospital stay, Rate of dislodgement/blockage of cholecystostomy tube and outcome after procedure (definitive management, planned cholecystectomy). Inclusion criteria: High risk patients with multiple comorbidities (ASA 2–4) who presented with acute cholecystitis and underwent laparoscopic cholecystostomy after failed conservative management were included in this study. Exclusion criteria: Those patients who had either hepato-pancreatic-biliary malignancy (HPB) or ascites, and those who underwent open cholecystostomy were excluded from the study. Results In group A, 7 patients were females and 4 were males while in Group B, 9 patients were females and 9 were males. 8 patients in group A had the procedure over night while only 3 patients had the procedure during day while in group B, only 1 patient had procedure during the night and the rest of them had procedure during the day. All the patients in group A had their cholecystectomy except one who died within 30 days of the cholecystostomy. In group B, only 6 patients had further LC while 12 patients did not require further operation. Out of all the patients, only 1 patient in each group died within 30 days after the procedure. None of the patients experienced one year mortality after the procedure in group A whereas, in group B, 7/18 patients died within 1 year after the procedure. Dislodgment of drain occurred in 2/11 patients in the group A and 4/18 patients in the group B. None of the patients in both the groups A &amp; B had any post cholecystostomy complications. Conclusions This study concludes that Laparoscopic cholecystostomy can be as a viable alternative to open cholecystectomy in technically difficult cases and alternative to percutaneous cholecystostomy in hospitals without interventional radiology services or during the times when IR services are not available.

1038 Improving Adherence to Antibiotic Guidelines for the Treatment of Acute Cholecystitis: A Completed Audit Cycle

Abstract Aim Acute cholecystitis (AC) accounts for up to one third of emergency surgical admissions. The initial management of AC includes fluid resuscitation and appropriate antibiotic therapy. The aim of this study is to audit compliance with local microbiology guidelines for the treatment of AC and to develop interventions that improve compliance rates. Method All patients admitted from September to December 2020 with radiologically confirmed AC were included in an initial prospective audit (n=39 patients). Antibiotic prescriptions, patient demographics, presence of fever (&amp;gt;38°C), inflammatory markers and liver function tests were recorded. The results were disseminated, educational material produced, and antibiotic “champions” appointed to improve adherence to antibiotic guidelines. A prospective re-audit was conducted from May to June 2021 to establish the effectiveness of the interventions (n=49 patients). Compliance rates before and after the interventions were compared using a Chi-squared test. Binomial logistic regression was carried out to establish whether any patient demographic or clinical parameters were independent predictors of prescribing behaviour. Results Compliance to antibiotic guidelines for AC significantly improved following the interventions (12.8% vs 57.1%; p&amp;lt;0.001). Age, gender, temperature, inflammatory markers, and liver function tests were comparable in both groups and were not found to be independent predictors of non-compliant antibiotic prescription. Conclusions Adherence to antibiotic guidelines for AC can be improved with educational interventions and the appointment of individuals responsible for ensuring correct prescribing behaviour. Interestingly, patient demographics, signs of sepsis or liver function did not influence prescribing behaviour, suggesting that divergence from antibiotic guidelines may be due to ingrained prescribing dogma.

SP4.2.1 Emergency management of lower GI bleeds: a full-cycle audit of practice at a district general hospital

Abstract Introduction Lower GI bleeds (LGIB) are a common cause of emergency surgical admission. National Guidelines on the management of LGIB were published by the British Society of Gastroenterologists (BSG) in 2019. The aim of our audit was to determine whether local practice of managing LGIB adhered to these guidelines. Method Our initial audit cycle retrospectively reviewed 47 patients with LGIB who had presented to our Hospital. Subsequently, a departmental teaching session was conducted and posters outlining BSG guidelines were placed on surgical wards and the surgical assessment unit. A re-audit of local practice was prospectively undertaken with 30 patients. Results In the initial audit cycle 37/47 (78.7%) patients had a major LGIB (Oakland score &amp;gt;8) where admission is advised. Of these, 6 (16%) were discharged on the same day. Of the 10/47 (21.3%) patients who had a minor LGIB, 6 (60%) were discharged on the same day. In the re-audit cycle, 29/30 (96.7%) patients had a major LGIB and 1/30 had a minor LGIB, none of these patients were discharged on the same day. The re-audit population had a higher rate of inpatient endoscopy, 66.7% vs 14.9%. 50% of unstable patients had a CT angiogram on admission in the re-audit vs 0% patients in the first cycle. Discussion Following education, compliance to BSG guidelines improved. Discharges in patients with major LGIB reduced to zero following this audit and more patients received appropriate inpatient investigations. Further work is required to see if change in local practice has an impact on clinical outcomes.

EP-213 An Audit on the Initial Management of Acute Cholecystitis: A Single Centre Experience

Abstract Aim Acute cholecystitis (AC) accounts for up to one third of emergency surgical admissions. The initial management of AC includes fluid resuscitation and appropriate antibiotic therapy. The aim of this study is to audit compliance with local microbiology guidelines for the treatment of AC and to develop interventions that improve compliance rates. Method All patients admitted from September to December 2020 with radiologically confirmed AC were included in an initial prospective audit (n=39 patients). Antibiotic prescriptions, patient demographics, presence of fever (&amp;gt;38°C), inflammatory markers and liver function tests were recorded. The results were disseminated, educational material produced, and antibiotic “champions” appointed to improve adherence to antibiotic guidelines. A prospective re-audit was conducted from May to June 2021 to establish the effectiveness of the interventions (n=49 patients). Compliance rates before and after the interventions were compared using a Chi-squared test. Binomial logistic regression was carried out to establish whether any patient demographic or clinical parameters were independent predictors of prescribing behaviour. Results Compliance to antibiotic guidelines for AC significantly improved following the interventions (12.8% vs 57.1%; p&amp;lt;0.001). Age, gender, temperature, inflammatory markers and liver function tests were comparable in both groups and were not found to be independent predictors of non-compliant antibiotic prescription. Conclusions Adherence to antibiotic guidelines for AC can be improved with educational interventions and the appointment of individuals responsible for ensuring correct prescribing behaviour. Interestingly, patient demographics, signs of sepsis or liver function did not influence prescribing behaviour, suggesting that divergence from antibiotic guidelines may be due to ingrained prescribing dogma.

The spectrum and outcome of paediatric emergency surgical admissions - a regional hospital analysis

BACKGROUND: Improving emergency surgical care for children requires information on the causes of admissions and the variables affecting outcome. There is a lack of such data in the South African context. METHODS: This retrospective study was conducted from January 2016 to December 2017. Data was collected on all children (&lt; 12 years of age) requiring admission with emergency surgical conditions. Infrastructure and staffing ratios were determined prior to data collection. Information was sourced from admission and discharge books, patient files and theatre registers. Variables of age, sex, referral source, diagnosis, length of stay, surgical treatment and outcome including death were collected. RESULTS: Four hundred and thirty-five of the 1 048 children (42%) admitted were in the 0-2-year age group. Trauma (258), sepsis (564) and burns (226) were the main causes. The median hospital stay was 3 days (IQR 2-5), however, for burns patients, the median stay was 4 days (IQR 2-9). Surgery was performed on 279 (27%) admissions. Eight (0.8%) died, six of which were due to burns. Clinical status prior to death was poorly documented. A dedicated high care unit and burns isolation rooms were lacking. Surgeon/population and child/nurse ratios were respectively 1.48/100 000 and 7-12/1. CONCLUSION: This study found that the emergency paediatric surgical burden is significant. Sepsis and trauma combined are the leading cause of emergency admissions. Burns had the highest mortality. Although mortality was low, improvements of staff to patient ratios and the institution of an early warning system could reduce mortality.

The weekend effect on the provision of Emergency Surgery before and during the COVID-19 pandemic: case\u2013control analysis of a retrospective multicentre database

IntroductionThe concept of “weekend effect”, that is, substandard healthcare during weekends, has never been fully demonstrated, and the different outcomes of emergency surgical patients admitted during weekends may be due to different conditions at admission and/or different therapeutic approaches. Aim of this international audit was to identify any change of pattern of emergency surgical admissions and treatments during weekends. Furthermore, we aimed at investigating the impact of the COVID-19 pandemic on the alleged “weekend effect”.MethodsThe database of the CovidICE-International Study was interrogated, and 6263 patients were selected for analysis. Non-trauma, 18+ yo patients admitted to 45 emergency surgery units in Europe in the months of March–April 2019 and March–April 2020 were included. Demographic and clinical data were anonymised by the referring centre and centrally collected and analysed with a statistical package. This study was endorsed by the Association of Italian Hospital Surgeons (ACOI) and the World Society of Emergency Surgery (WSES).ResultsThree-quarters of patients have been admitted during workdays and only 25.7% during weekends. There was no difference in the distribution of gender, age, ASA class and diagnosis during weekends with respect to workdays. The first wave of the COVID pandemic caused a one-third reduction of emergency surgical admission both during workdays and weekends but did not change the relation between workdays and weekends. The treatment was more often surgical for patients admitted during weekends, with no difference between 2019 and 2020, and procedures were more often performed by open surgery. However, patients admitted during weekends had a threefold increased risk of laparoscopy-to-laparotomy conversion (1% vs. 3.4%). Hospital stay was longer in patients admitted during weekends, but those patients had a lower risk of readmission. There was no difference of the rate of rescue surgery between weekends and workdays. Subgroup analysis revealed that interventional procedures for hot gallbladder were less frequently performed on patients admitted during weekends.ConclusionsOur analysis revealed that demographic and clinical profiles of patients admitted during weekends do not differ significantly from workdays, but the therapeutic strategy may be different probably due to lack of availability of services and skillsets during weekends. The first wave of the COVID-19 pandemic did not impact on this difference.