General Surgery Patients Research Articles

72nd Southwestern Surgical Congress Claude H. Organ, Jr. memorial lecture: Rise ofacutecareroboticsurgery forcommonemergencygeneralsurgeryconditions

Dr. Claude Organ rose above poverty, racism, and untold insurmountable odds to become a masterful surgeon and revered leader in numerous academic and professional circles. But it's his impact on surgical education and his philosophy to “teach, give back, and keep advancing” that inspired this lecture. Acute care robotic surgery (ACRS) utilizes the strengths of robotic assisted laparoscopic surgery (RALS) for a high-volume population of emergency general surgery (EGS) patients. The future benefits of ACRS may include improvements in resident training, patient safety, and outcomes. General surgery residencies that have a robust ACRS program are likely to be more competitive than those without.

EP.FRI.508 Improving Antibiotic Stewardship on General Surgical Wards

Abstract Aims Good antibiotic stewardship is a core part of patient care. It has been shown to reduce antibiotic resistance and improve overall patient outcomes. The primary aim was to improve compliance with national antibiotic prescribing guidance. In doing so, we sought to improve documentation of antibiotic duration; reduce the duration of intravenous antibiotics and gentamicin courses; and length of stay in hospital. Methods 50 general surgery inpatients at a district general hospital over a 2-week period were included in cycle 1. All eligible patients on antibiotics were included. Patients were excluded if under 18 years; discharged within 24 hours; or on antibiotics for prophylaxis. Intervention was a poster and education sessions with prescribers. Cycle 2 gathered data from a further 50 patients from the same wards over 10 days. Results There were improvements in documentation of antibiotic duration (from 1% to 52%, p = 0.001); prescription of antibiotics in line with guidance (from 74% to 90%, p = 0.0376) and number of patients on intravenous antibiotics (reduced from 89% to 72%, p = 0.0307). Duration of gentamicin courses also improved: from 23% patients getting more than 72 hours of gentamicin, to 0% post intervention. Length of stay was also reduced, however was not statistically significant (4.98 days to 4.10 days, p = 0.259). Conclusions This simple audit intervention improved antibiotic stewardship on surgical wards, which is an essential part of overall care for patients. Future work could be done to further improve on this, including a prompt via electronic prescribing and targeted interventions in other clinical areas, e.g. ICU.

A National Evaluation of Ambulatory Surgery Utilization Among Emergency General Surgery and Trauma Patients

Introduction: Ambulatory Surgery Centers (ASCs) are increasingly prevalent in the United States. Acute Care Surgery (ACS) patients — defined as emergency general surgery (EGS) and trauma patients — comprise 20% of the inpatient population and 25% of total inpatient costs, but the volume of outpatient ACS procedures has not been characterized. We quantified the national burden and costs of ACS procedures occurring in ASCs. Methods: We queried the 2017 Nationwide Ambulatory Surgery Sample (NASS), a newly-released national all-payer ambulatory surgery database. We included patients ≥18 years with EGS or trauma as defined by the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. The primary outcome was total charges;the secondary outcome was discharge disposition. Results: Among 9 million ambulatory surgery patients, 772,484 (8.2%) had an EGS diagnosis and 1,073,734 (11.4%) had a trauma diagnosis. Total costs for ACS patients were $38.3 billion, or 18.0% of outpatient surgical costs. EGS patients had higher rates of routine discharge home than trauma patients (99.4% vs. 98.0%, p<0.001);remaining patients required transfer to inpatient hospitals. Patients most likely to be discharged home included those with cholecystitis (aOR 3.7), hernia surgery (aOR 4.4), self-pay patients (aOR 2.1), and those treated at urban hospitals (aOR 1.6) (p<0.001). Conclusion: ACS patients comprise 20% of the outpatient surgical population and 18% of ASC costs. The growing importance of ASCs is highlighted by the COVID-19 pandemic, suggesting an opportunity to conserve inpatient resources and relocate additional ACS procedures to the outpatient setting.

Neuraxial and Regional Anesthesia Reduces the Risk of Venous Thromboembolism in General Surgery Patients

Neuraxial and Regional Anesthesia Reduces the Risk of Venous Thromboembolism in General Surgery Patients

Geriatric Surgical Service Complements Care of Older Adult Emergency General Surgery Patients

Introduction: Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. In this study, we identified geriatric surgical service interventions most relevant to EGS patients. Methods: We conducted a retrospective chart review of patients >75 years admitted to the EGS service at our urban tertiary care hospital with a score >3 by the FRAIL scale, a five-point frailty screening instrument, or history of dementia. The geriatric surgical service, led by a dually-board certified geriatric and palliative care specialist, consulted on these patients from January 2020-January 2021;a hiatus was taken for the COVID-19 pandemic. Consults included a comprehensive geriatric assessment and calculated a modified Rockwood Frailty Index. Hospital admission characteristics and consultation components were collected via chart review. Results: Forty patients were evaluated (median age 82 years (IQR 78-89), 55.0% female). The most common admission diagnosis was small bowel obstruction (32.5%). 62.5% of patients underwent >1 surgical procedure. Median time to geriatric consult from admission was 3 days (IQR 1.0-4.3). By Frailty Index, 58% were moderately or severely frail. Interventions included medication changes (97.5%), symptom management (82.5%), delirium prevention and management (65.0%), mobility and function recommendations (65.0%), serious illness conversations (55.0%), and code status change (17.5%). Conclusion: Geriatric service involvement identifies and addresses a high burden of both geriatric and palliative care needs in older adult EGS patients.

Eye vs AI: Accuracy of Risk Estimation for Surgeons Risk Calculators in Emergency General Surgery Patients

Eye vs AI: Accuracy of Risk Estimation for Surgeons Risk Calculators in Emergency General Surgery Patients

Early Initiation of Parenteral Nutrition in Elderly Emergency General Surgery Patients

Early Initiation of Parenteral Nutrition in Elderly Emergency General Surgery Patients

Opioid reduction and elimination in pediatric surgical patients

Opioid overuse is a national concern. Mitigation strategies include judicious prescribing and encouragement of non-opioid therapies. This quality improvement project aimed to identify physician opioid prescribing and patient usage patterns at a pediatric academic center. Patients who underwent same-day general, orthopedic, or plastic surgery procedures were contacted 7 - 28 days post-operatively. Inquiries were made about opioid usage, non-opioid strategies, and overall pain management satisfaction. A subset of general surgery patients not prescribed opioids was compared to those prescribed opioids. Between August 2017 - May 2020, 558 surveys were obtained. There was a significant increase in the use of non-opioid therapies between 2017 and 2020 (83.5% vs 97%, p=0.04). Almost all patients' opioid prescriptions were filled; however, 78-98% had leftover opioids. Only 20-25% disposed the excess opioids. In subset analysis of general surgery patients, no inguinal hernia or orchiopexy patient who was discharged without opioids required opioids later. More non-opioid patients used other therapies (acetaminophen, heat (p=0.03)); however, pain management satisfaction was higher in the opioid group (99% vs 94%, p=0.01). While our opioid prescribing has decreased, physicians are still prescribing more opioids than patients require. Further education on non-opioid pain therapies and proper disposal of opioids are needed. III TYPE OF STUDY: prospective quality improvement study.

279 Preparing Foundation Trainees for Surgical On-Calls

Abstract Aim Foundation trainee feedback has highlighted low levels of confidence with the prospect of surgical on-calls. Key areas of concern are assessing and managing the acute surgical patient, identifying which patients need an operation and having the technical skills to competently assist in theatre. This lack of confidence prevents trainees engaging in an educational and rewarding rotation. We have designed and facilitated a day of robust workshops, addressing these key educational needs. Method Pre and post course questionnaires assessed the efficacy of teaching. Lectures on the assessment and management of acute surgical patients in general surgery, urology and trauma and orthopaedics were delivered by core surgical trainees. A named consultant oversaw quality assurance. Addressing the technical skills development need, an afternoon of surgical skills workshops covered, suturing, knot tying, laparoscopic principles, and theatre etiquette. Small groups of trainees rotated through each workshop, delivered by senior specialty trainee registrars, to ensure high fidelity training Results Trainees rated themselves in key areas pre and post course on a scale from 1-5. Pre course, 66% of trainees scored 3+ in “confidence in managing a surgical patient on-call”. This rose to 100% post course. Similarly; “Confidence in decision making regarding whether a patient should proceed to theatre” increased from 37.5% to 93.7%. “Suturing skills” improved from 37.5% to 100%. Conclusions All trainees that attended the course displayed marked improvement in their confidence and competence. We feel this course or similar should be incorporated into the foundation teaching program locally and has scope to be expanded regionally.

347 Read the First Page: An Audit on Medicine Reconciliation in General Surgery Inpatients at London District General Hospital

Abstract Aim Medication-related incidents occur more frequently when medicine reconciliation happens more than 24 hours after admission. The National Institute for Health and Care Excellence recommends a complete reconciliation within 24 hours of admission. General Surgery is a busy specialty with a high patient turnover rate. Hence, this audit was conducted to assess the extent of a problem and mitigate it. Method Every adult General Surgery inpatient who were admitted for over 24 hours were included. Patients on intensive care or high dependency unit were excluded. Drug charts were reviewed every Thursday for nine weeks between October and December 2020. Data from the first three weeks were used to establish baseline. Three interventions were introduced, each lasting two weeks. Any significant harm to patients due to incomplete reconciliation was recorded. Results At baseline (n = 100), 38.0% of patients had incomplete reconciliation. This significantly reduced to 23.4% (n = 64, p-value=0.037) between Weeks 4 and 5 after baseline data was presented at a team meeting and posters were put up. Allowing pharmacists to flag up missing medications on a daily job’s list did not significantly reduce the incompletion rate (23.0%, n = 74, p-value&amp;gt;0.999). Finally, performing a medicine reconciliation ward round on Weeks 8 and 9 further reduced the incompletion rate to 2.8% (n = 74, p-value=0.001). One significant harm was noted on Week 1. Conclusions Medicine reconciliation is a vital aspect of patient safety. Raising awareness of the issue significantly reduced the incompletion rate. However, the most effective intervention is conducting a medicine reconciliation ward round.

1364 Quality Control of Discharge Summaries for Endocrine Surgery Patients; A Closed Loop Audit

Abstract Aim A patient's discharge summary (TTO) should be accurate. Most of them are conducted by junior doctors at the beginning of their medical training. The information mentioned in a TTO ensures patient safety, continuity of care as well as correct clinical coding for the NHS. Therefore, a re-audit was designed to check the quality of the discharge summaries of endocrine surgical patients In Nottingham City Hospital i.e., the type of operation, diagnosis, or postoperative instructions. Method The first cycle included all the TTOs for the endocrine surgical patients operated from April 2018 to November 2018. Then we re-audited those who had endocrine surgeries from April 2019 to November 2019. NOTIS e-TTO, Bluespier theatre lists and Medway were used to retrieve the data. All general surgery patients were excluded. Results 142 and 104 patients TTOs were included in each audit cycle, respectively. Type of operation was improved from 84% to 95% in the second cycle. Correct diagnosis was reported from 68% to 72% in the second cycle audit. Conclusions The introduction of electronic operation notes in our practice improved the correct clinical coding for the type of operation mentioned in the TTO. The accuracy of correct diagnosis remains suboptimal. Therefore, education of junior doctors and an idea of double-checking from a more senior colleague should be assessed.

935 Identification and Management of Electrolyte Abnormalities in Surgical Patients Requiring Total Parenteral Nutrition: An Audit of Current Practice at A University Hospital

Abstract Aim Electrolyte abnormalities are a common and serious consequence of nutritional deficiencies when patients are nil-by-mouth. Timely intervention with a multidisciplinary approach is known to improve outcome. This audit aimed to assess adequacy of initial electrolyte management and timing of dietetics referral in acute surgical patients requiring total parenteral nutrition in a university hospital. Method A retrospective audit of all general surgery patients referred to dietetics for total parenteral nutrition between January-December 2019 was performed. The following audit standards (from the time following admission) were applied: monitoring of electrolytes every 48-hours, treatment of electrolyte abnormalities within 24-hours of discovery; and referral to the dietetics service within 48-hours of nil-by-mouth being commenced. Results Data from 52 patients (27 females, median age 66) were analysed. Fifty-one (98%) had electrolytes measured every 48-hours, however magnesium, phosphate and/or calcium were not measured prior to dietetics input in 9 (17%). Forty electrolyte abnormalities requiring treatment were found in 28 patients (54%), though only 18 (64%) commenced treatment within 24-hours. The most common electrolyte abnormalities not corrected within 24-hours were phosphate and calcium (50%). 46% of patients were referred to dietetics after 48-hours of nil-by-mouth status. Conclusions In our unit, we found that basic electrolytes were frequently monitored in patients placed nil-by-mouth, however calcium, phosphate and magnesium were often omitted prior to dietetics input, and correction of abnormalities was sometimes delayed. Introduction of a local protocol-based approach for electrolyte monitoring with streamlined dietetics referrals is likely to improve adherence to best practice.

1369 Clinical Outcomes in Patients Undergoing Emergency General Surgery During the Covid-19 Pandemic Versus Control Patients: A Systematic Review and Meta-Analysis

Abstract Introduction Throughout the Covid-19 pandemic, the surgical community has attempted to address whether it is safe to continue surgery. The aim of this research was to review evidence on emergency general patients operated on during the pandemic compared to patients undergoing emergency surgery during non-pandemic times to determine if operating during the Covid-19 pandemic led to an increased risk of death, length of hospital stay and complications. Method A systematic review of the literature was performed. PubMed, Cochrane, MEDLINE, Science Direct, Springer Link, Elsevier, and reference lists were analysed for inclusion on 2 January 2021. Results Nine studies and 5,022 patients were included. There were no significant differences in the control group vs pandemic group in mean age (52.3yrs vs 51.9yrs, p = 0.67) or gender (44.4% females vs 49.3%, p = 0.173). Pooled analysis of control vs pandemic showed a mortality rate of 1.26% vs 3.06% (CI:-6.58–6.58, p = 1.00). Mean length of hospital stay was 7.9 vs 7.7 days in control v. pandemic (CI: -2.93-3.33, p = 0.87) and post-operative complication rate of 20.2% vs 25.7% (CI -6.4-25.0, p = 0.20), (control vs pandemic). The pandemic group had significantly more operative management (47.0% vs 40.0%, p = 0.03) with no significant difference in laparoscopic vs open technique (46.0% vs 43.6%, p = 0.20). Conclusions This meta-analysis shows there is no statistically significant difference in mortality rate, length of hospital stay and postoperative complication rate between the pandemic and control cohorts in emergency general surgery patients. This data suggests that general emergency surgery should continue in spite of the pandemic with appropriate precautions in place.

Structures, processes and models of care for emergency general surgery in Ontario: a cross-sectional survey.

Background:Emergency general surgery (EGS) patients require urgent surgical evaluation and intervention for various conditions, such as infectious or obstructive diseases of the gastrointestinal tract. We aimed to characterize the structures and processes that are relevant to the delivery of EGS care across Ontario hospitals and to evaluate the availability of critical resources at hospitals with formal EGS models.Methods:Between August 2019 and July 2020, we conducted a cross-sectional survey of Ontario hospitals that offered urgent general surgery (defined as the ability to provide nonelective surgical intervention within 24 to 48 hours of presentation) to adults. People with intimate knowledge of their hospital’s EGS program completed a Web-based or telephone survey characterizing the program’s organizational structure and staffing, operating room availability, interventional radiology and interventional endoscopy availability, intensive care unit availability and staffing, and regional participation. Their responses were compiled and comparisons were made between hospitals with and without formal EGS models of care, as well as between hospitals based on size and academic status.Results:Of the 114 Ontario hospitals identified, 109 responded (95.6% response rate). A third (34.6%; n = 37/107) of hospitals had EGS models of care. Thirty-four of these (91.9%) were large (> 100-bed) institutions that would be likely to have increased resources. However, even for hospitals of similar size, those with EGS models had increased staffing levels compared to those without (clinical associates 17.6% [n = 3/17] v. 10.0% [n = 2/20]; nurse practitioners or physician assistants 27.8% [n = 5/18] v. 14.3% [n = 3/21]). They also had better access to diagnostic and interventional equipment (24/7 access to computed tomography 94.1% [n = 16/17] v. 69.2% [n = 18/26]), interventional radiology (88.9% [n = 16/18] v. 42.3% [n = 11/26]), endoscopy (100% [n = 18/18] v. 69.2% [n = 18/26]) and endoscopic retrograde cholangiopancreatography (77.8% [n = 14/18] v. 42.3% [n = 11/26]), as well as dedicated operating room time (72.2% [n = 13/18] v. 0% [n = 0/25]).Interpretation:The structures and processes available to care for patients requiring EGS in Ontario were highly variable between hospitals. Hospitals with formal EGS models were more likely to have access to key resources.

High Resource Utilization in Emergent Versus Elective General Surgery

In an era of pay for performance metrics, we sought to increase understanding of factors driving high resource utilization (HRU) in emergent (EGS) versus same-day elective (SDGS) general surgery patients. General surgery procedures from the 2016 ACS-NSQIP public use file were grouped according to the first four digits of the primary procedure CPT code. Groups having at least 100 of both elective and emergent cases were included (22 groups; 83,872 cases). HRU patients were defined as those in-hospital >7D, returned to the OR, readmitted, and/or had morbidity likely requiring an intensive care unit (ICU)stay. Independent NSQIP predictors of HRU were identified through forward regression; P for entry < 0.05, for exit > 0.10. Of all patients, 33% were HRU. The three highest HRU procedures (total colectomy, enterolysis, and ileostomy) comprised a higher proportion of EGS than SDGS cases (10.3 versus 2.6%, P < 0.001). The duration of operation was 40 Min lower in EGS after adjustment. Thirty-nine of the remaining 40 HRU predictors were higher in EGS including preoperative SIRS/Sepsis (50 versus 2%), ASA classification IV-V (31 versus 5%), albumin <3.5 g/dL (40 versus 12%), transfers (26 versus 2%, P's < 0.001), septuagenarians (35 versus 25%) and disseminated cancer (6.3 versus 4.8%, P's < 0.001); while sex did not differ. After adjustment, EGS patients remained more likely to be HRU (odds ratio 2.5, 95% CI 2.4 - 2.6, P < 0.001). EGS patients utilize significantly more resources than SDGS patients above what can be adjusted for in the clinically robust ACS-NSQIP dataset. Distinctive payment and value-based performance models are necessary for EGS.

Venous Thromboembolism Chemoprophylaxis in Trauma and Emergency General Surgery Patients: A Systematic Review.

Appropriate venous thromboembolism (VTE) chemoprophylaxis in trauma and emergency general surgery (EGS) patients is crucial. The purpose of this study is to review the recent literature and offer recommendations for VTE chemoprophylaxis in trauma and EGS patients. We conducted a literature search from 2000 to 2021 for articles investigating VTE chemoprophylaxis in adult trauma and EGS patients. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our search resulted in 34 articles. Most studies showed low-molecular-weight heparin (LMWH) is similar to unfractionated heparin (UFH) for VTE prevention; however, LMWH was more commonly used. Adjusted chemoprophylaxis dosing did not change the VTE rate but the timing did. Direct oral anticoagulants (DOACs) have been shown to be safe and effective in trauma and traumatic brain injury (TBI)/spinal cord injury (SCI). Studies showed VTE prophylaxis in EGS can be inconsistent and improves with guidelines that lower VTE events. There may be no benefit to receiving LMWH over UFH in trauma patients. In addition, different drugs under the class of LMWH do not change the incidence of VTE. Adjusted dosing of enoxaparin does not seem to affect VTE incidence. The use of DOACs in the trauma TBI and SCI setting has been shown to be safe and effective in reducing VTE. One important consideration with VTE prophylaxis may be the timing of prophylaxis initiation, specifically as it relates to TBI, with a higher likelihood of developing VTE as time progresses. EGS patients are at a high risk of VTE. Improved compliance with clinical guidelines in this population is correlated with decreased thrombotic events.

Venous Thromboembolism Chemoprophylaxis in Trauma and Emergency General Surgery Patients: A Systematic Review.

Journal of Trauma Nursing: September/October 2021 - Volume 28 - Issue 5 - p E10 doi: 10.1097/JTN.0000000000000611

Post-operative surgical site infection among general surgery patients: Rate and risk factors.

Objectives: High rate of post-surgical infections are reported with scanty effort for controlling them. The objectives were to evaluate frequency of surgical site infections in patients undergoing general surgery. Study Design: Cross Sectional Observational Study. Setting: Naz Memorial Hospital. Period: March 2019 to March 2020. Material &amp; Methods: This study was conducted in general surgery ward for 1 year. All patients over 18 years admitted in surgery ward either as elective or emergency case were included while patients having any wound infection, operated in other hospital or diabetic foot and all those operated for incision and drainage of abscess were excluded. All patients that were operated during the study period were followed for any wound infection development till one qAqmonth. SPSS was used for data entry and analysis keeping p-value of &lt;0.05 as significant. Results: 75 from 200 patients developed surgical site infection, 46 (61.3%) were operated in emergency. Among 24 contaminated surgeries type, 70.8% were reported having SSI (p-0.05) while from 28 dirty types of surgeries 78.6% of patients had a SSI (p-0.03). 25% were anemic, 21% diabetic while (20%) were reported to be hypertensive, 13 (17%) gave positive history of smoking while 12 (16%) were obese. Conclusion: Higher proportion of surgical site infection was observed in patients undergoing contaminated and dirty type of surgeries. Most patients with SSI were operated in emergency setting and anemia and diabetes were the most common risk factor reported in the infected patients.

Analysis of Related Factors of Incision Infection in General Surgery Patients

Analysis of Related Factors of Incision Infection in General Surgery Patients

Emergency General Surgery Regionalization: Retrospective Cohort Study of Emergency General Surgery Patients at a Tertiary Care Center.

Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources. We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients. Of 14714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different (P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts (P < .05). EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.