General Surgery Service Research Articles

Ninety-day readmissions after inpatient cholecystectomy: A 5-year analysis.

AIMTo determine the incidence of readmission after cholecystectomy using 90 d as a time limit.METHODSWe retrospectively reviewed all patients undergoing cholecystectomy at the General Surgery and Digestive System Service of the University Hospital of Guadalajara, Spain. We included all patients undergoing cholecystectomy for biliary pathology who were readmitted to hospital within 90 d. We considered readmission to any hospital service as cholecystectomy-related complications. We excluded ambulatory cholecystectomy, cholecystectomy combined with other procedures, oncologic disease active at the time of cholecystectomy, finding of malignancy in the resection specimen, and scheduled re-admissions for other unrelated pathologies.RESULTSWe analyzed 1423 patients. There were 71 readmissions in the 90 d after discharge, with a readmission rate of 4.99%. Sixty-four point seven nine percent occurred after elective surgery (cholelithiasis or vesicular polyps) and 35.21% after emergency surgery (acute cholecystitis or acute pancreatitis). Surgical non-biliary causes were the most frequent reasons for readmission, representing 46.48%; among them, intra-abdominal abscesses were the most common. In second place were non-surgical reasons, at 29.58%, and finally, surgical biliary reasons, at 23.94%. Regarding time for readmission, almost 50% of patients were readmitted in the first week and most second readmissions occurred during the second month. Redefining the readmissions rate to 90 d resulted in an increase in re-hospitalization, from 3.51% at 30 d to 4.99% at 90 d.CONCLUSIONThe use of 30-d cutoff point may underestimate the incidence of complications. The current tendency is to use 90 d as a limit to measure complications associated with any surgical procedure.

Epidemiologic analysis: Prophylaxis and multidrug-resistance in surgery

BackgroundSurgical site infection is defined as an infection related to the surgical procedure in the area of manipulation occurring within the first 30 postoperative days. The diagnostic criteria include: purulent drainage, isolation of microorganisms, and signs of infection. AimsTo describe the epidemiologic characteristics and differences among the types of prophylactic regimens associated with hospital-acquired infections at the general surgery service of a tertiary care hospital. Material and methodsThe electronic case records of patients that underwent general surgery at a tertiary care hospital within the time frame of January 1, 2013 and December 31, 2014 were reviewed. A convenience sample of 728 patients was established and divided into the following groups: Group 1: n=728 for the epidemiologic study; Group 2: n=638 for the evaluation of antimicrobial prophylaxis; and Group 3: n=50 for the evaluation of multidrug-resistant bacterial strains in the intensive care unit. The statistical analysis was carried out with the SPSS 19 program, using the Mann-Whitney U test and the chi-square test. ResultsA total of 728 procedures were performed (65.9% were elective surgeries). Three hundred twelve of the patients were males and 416 were females. Only 3.98% of the patients complied with the recommended antimicrobial prophylaxis, and multidrug-resistant bacterial strains were found in the intensive care unit. DiscussionA single prophylactic dose is effective, but adherence to this recommendation was not adequate. ConclusionsThe prophylactic guidelines are not strictly adhered to in our environment. There was a significant association between the development of nosocomial infections from multidrug-resistant germs and admission to the intensive care unit.

Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trial

The role of incretin-based drugs in the treatment of patients with type 2 diabetes admitted to hospital has not been extensively assessed. In this study, we compared the safety and efficacy of a dipeptidyl peptidase-4 inhibitor (sitagliptin) plus basal insulin with a basal-bolus insulin regimen for the management of patients with type 2 diabetes in general medicine and surgery in hospitals. We did a multicentre, prospective, open-label, non-inferiority randomised clinical trial (Sita-Hospital) in five hospitals in the USA, enrolling patients aged 18-80 years with type 2 diabetes and a random blood glucose concentration of 7·8-22·2 mmol/L who were being treated with diet or oral antidiabetic drugs or had a total daily insulin dose of 0·6 units per kg or less, admitted to general medicine and surgery services. We randomly assigned patients (1:1) to receive either sitagliptin plus basal glargine once daily (the sitagliptin-basal group) or a basal-bolus regimen with glargine once daily and rapid-acting insulin lispro or aspart before meals (the basal-bolus group) during the hospital stay. All other antidiabetic drugs were discontinued on admission. The randomisation was achieved by computer-generated tables with block stratification according to randomisation blood glucose concentrations (ie, higher or lower than 11·1 mmol/L). The primary endpoint of the trial was non-inferiority in mean differences between groups in their daily blood glucose concentrations during the first 10 days of therapy (point-of-care measurements; non-inferiority was deemed a difference <1 mmol/L). The safety endpoints included hypoglycaemia and uncontrolled hyperglycaemia leading to treatment failure. All participants who received at least one dose of study drug were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT01845831. Between Aug 23, 2013, and July 27, 2015, we recruited 279 patients, and randomly assigned 277 to treatment; 138 to sitagliptin-basal and 139 to basal-bolus. The length of stay in hospital was similar for both groups (median 4 days [IQR 3-8] vs 4 [3-8] days, p=0·54). The mean daily blood glucose concentration in the sitagliptin-basal group (9·5 mmol/L [SD 2·7]) was not inferior to that in the basal-bolus group 9·4 mmol/L [2·7]) with a mean blood glucose difference of 0·1 mmol/L (95% CI -0·6 to 0·7). No deaths occurred in this trial. Treatment failure occurred in 22 patients (16%) in the sitagliptin-basal group versus 26 (19%) in the basal-bolus group (p=0·54). Hypoglycaemia occurred in 13 patients (9%) in the sitagliptin-basal group and in 17 (12%) in the basal-bolus group (p=0·45). No differences in hospital complications were noted between groups. Seven patients (5%) developed acute kidney injury in the sitagliptin-basal group and six (4%) in the basal-bolus group. One patient (0·7%) developed acute pancreatitis (in the basal-bolus group). The trial met the non-inferiority threshold for the primary endpoint, because there was no significant difference between groups in mean daily blood glucose concentrations. Treatment with sitagliptin plus basal insulin is as effective and safe as, and a convenient alternative to, the labour-intensive basal-bolus insulin regimen for the management of hyperglycaemia in patients with type 2 diabetes admitted to general medicine and surgery services in hospital in the non-intensive-care setting. Merck.

Frequency and cost of acute surgical admissions in over-anticoagulated patients: over-anticoagulation in the community.

Anticoagulation treatment in the community is common. This investigation was undertaken to determine the frequency of patient surgical admission with conditions associated with over-anticoagulation in the community and the surgical resource required to effectively and safely manage these patients acutely. Hospital discharge data on individual patients admitted to Waitemata District Health Board hospitals between December 2014 and November 2015 inclusive were reviewed. Data were extracted on individual patients with relevant ICD-10 codes (D683, Y442, Y443). Individual records for patients admitted to general surgery were then reviewed and costing information related to admissions extracted. A total of 551 patients were admitted in a 12-month period (4.8 admissions/1000 warfarin users and 2.4 admissions/1000 dabigatran users) for conditions associated with over-anticoagulation, with 35 admitted to the general surgery service, of whom 29 were taking warfarin and six taking dabigatran. A total of 21 patients were admitted with haemorrhagic conditions, and 14 over-anticoagulated patients were admitted with general surgical conditions requiring treatment. All patients were managed by withholding anticoagulant medication, 12 required formal reversal, three required red cell transfusion and four haemostatic procedures. The average hospital stay was 4 days, with inpatient costs of NZ$3500. Management of patients admitted with over-anticoagulation in the community is a significant surgical workload; however, acute management is usually straightforward.

Aspects épidemiologiques et thérapeutiques des hydrocèles vaginales au centre hospitalier régional de Dapaong (Togo)

ObjectivesTo describe the epidemiology and the treatment of vaginal hydrocele in a filarial endemic area. Patients and methodsThis was a retrospective descriptive study of patients admitted and treated in the General Surgery Service of the Regional Hospital of Dapaong (Togo) for hydrocele, diagnosed on clinical and paraclinical evidence. ResultsOne hundred and nineteen patients were operated over six years and represented 54% of the activity in urologic surgery. Among them, 19.3% were under fifteen years old and had the hydrocele since childhood, while the average disease duration was 9 years in adults. Hydrocele was bilateral in 15% of patients. Removal of the peritoneo-vaginal canal was accomplished in all patients under fifteen years and hydrocelectomy using the technique of Bergmann was conducted in adult patients. There was no mortality and the morbidity was 11%, mainly parietal suppuration and scrotal hematoma. ConclusionVaginal hydrocele is a frequent pathology in the tropics and requires surgical management. Reducing its impact in our communities can be accomplished through eradication of lymphatic filariasis.

Defining Communication Improvement Needs in General Surgery: An Analysis of Pages, Communications, Patterns, and Content☆?>

To describe patterns of pages communication to general surgery (GS) residents, identify the need for and develop strategies to improve interprofessional communication. Retrospective cohort study. General surgery (GS) service at a tertiary care academic institution, Sunnybrook Health Sciences Centre, in Toronto, Ontario, Canada. All pages sent to GS residents over 4 weeks at an academic institution. Timing, training level of receiver and content of pages were captured. Communication priority was assigned by 2 independent reviewers-low (121+ min), medium (31-120min), high (6-30min), and immediate (0-5min) priority. Overall, 2 independent reviewers analyzed pages' content through an inductive process, and generated themes. Of 2025 pages retrieved, 963 (47.5%) contained exclusively a call back number. A median of 74 pages per day (range: 43-116) were received, with median page interval of 9.4 minutes (range: 0-640). Junior residents received 79.5% of pages. Timing of the pages was 43.9% weekday shift, 31.8% weeknight shift, and 24.3% weekend call. Communication priority was deemed low for 35.4% of pages, medium for 32.3%, high for 12.4%, and immediate for 0.7%. Content analysis of 1062 pages generated 5 major themes: nonurgent medical issue (54.0%), administrative (15.3%), communication (13.5%), emergencies (4.8%), and GS consultation requests (4.0%). Priority and content of pages varied according to training level and page timing. Pages to GS residents were frequent and most often of low priority. They were seldom related to urgent medical matters. Education and new communication strategies are warranted to reduce low priority pages.

Development and Pilot Study of an Essential Set of Indicators for General Surgery Services

IntroductionAt present there is a lack of appropriate quality measures for benchmarking in general surgery units of Spanish National Health System. The aim of this study is to present the selection, development and pilot-testing of an initial set of surgical quality indicators for this purpose. MethodsA modified Delphi was performed with experts from the Spanish Surgeons Association in order to prioritize previously selected indicators. Then, a pilot study was carried out in a public hospital encompassing qualitative analysis of feasibility for prioritized indicators and an additional qualitative and quantitative three-rater reliability assessment for medical record-based indicators. Observed inter-rater agreement, prevalence adjusted and bias adjusted kappa and non-adjusted kappa were performed, using a systematic random sample (n=30) for each of these indicators. ResultsTwelve out of 13 proposed indicators were feasible: 5 medical record-based indicators and 7 indicators based on administrative databases. From medical record-based indicators, 3 were reliable (observed agreement >95%, adjusted kappa index >0.6 or non-adjusted kappa index >0.6 for composites and its components) and 2 needed further refinement. ConclusionsCurrently, medical record-based indicators could be used for comparison purposes, whilst further research must be done for validation and risk-adjustment of outcome indicators from administrative databases. Compliance results in the adequacy of informed consent, diagnosis-to-treatment delay in colorectal cancer, and antibiotic prophylaxis show room for improvement in the pilot-tested hospital.

Development of the 24/7 Nurse Practitioner Model on the Inpatient Pediatric General Surgery Service at a Large Tertiary Care Children's Hospital and Associated Outcomes

Nurse practitioners (NPs) have been providing high-quality and safe patient care for a few decades, and evidence showing the extent of their impact is emerging. This article describes the implementation of a 24/7 NP patient care model on an inpatient pediatric general surgery service in a tertiary free-standing Children's Hospital in the Northeastern United States. The literature shows that there is limited evidence regarding NP models of care and their effect on patient outcomes. In response to policy changes leading to reduction of resident work hours and a more acute and complex inpatient pediatric general surgery patient population, our existing NP model evolved into a 24/7 NP Model in June 2011. The results from two quality improvement projects showed positive registered nurse and attending surgeon staff satisfaction with the 24/7 NP Model of care and a decreased trend of unplanned intensive care unit patient transfers after the 24/7 NP Model implementation. These findings further support the evidence in the literature that NPs provide safe and quality patient care.

Elective Oncology Surgeries: Cancellations And Causes

The aim of this research was to identify the elective surgeries suspension rate and investigate the causes of its cancellation in general surgery service in highly complex hospital. Method: A descriptive, exploratory, prospective and quantitative study was conducted in a university hospital using data from scheduled and canceled elective surgeries in the period from July 2015 to July 2016, which were extracted from MV System. Results: 984 elective surgeries oncology were scheduled during one year, of which 423 (43.4%) were canceled. 258 (32.3%) cancellations occurred in the morning. The main reason for cancellation was related with the patient seen in 269 cases (63.6%). Conclusion: The number of cancellations was high, and the suspensions can and should be controlled and restricted. It is recommended the awareness of everyone involved in such a situation to which seeks a reduction in suspension rates and subsequently joint efforts to implement measures to restrict the most of this event.

Analysis of Risk Factors for Patient Readmission 30 Days Following Discharge From General Surgery.

Previous studies investigating patients at risk for hospital readmissions focus on medical services and have found chronic conditions as contributors. Little is known, however, of the characteristics of patients readmitted from surgical services. Surgical patients readmitted within 30 days following discharge were analyzed to identify opportunities for intervention in a cohort that may differ from the medical population. Medical record review of patients readmitted to any service within 30 days of discharge from the general surgery service to characterize index and readmission data between July 1, 2014, and June 30, 2015, at a Level I trauma center and safety-net hospital. Reasons for readmission identified by manual medical record review and risk factors identified via statistical analysis of all discharges during this period. One hundred seventy-three patients were identified as being unplanned readmissions within 30 days among 2100 discharges (8.2%). Of these 173 patients, 91 were men. Common reasons for readmission included 29 patients with injection drug use who were readmitted with soft tissue infections at new sites (16.8% of readmissions), 25 with disposition support issues (14.5%), 23 with infections not detectable during index admission (13.3%), and 16 with sequelae of their injury or condition (9.2%). Sixteen patients were identified as having a likely preventable complication of care (9.2%), and 2 were readmitted owing to deterioration of medical conditions (1.2%). On univariate and multivariate analyses, female sex (men to women risk of readmission odds ratio [OR], 0.5; 95% CI, 0.37-0.71; P < .001), presence of diabetes (OR, 1.7; 95% CI, 1.1-2.6; P = .009), sepsis on admission (OR, 1.7; 95% CI, 1.05-2.6; P = .03), or intensive care unit stay during index admission (OR, 1.7; 95% CI, 1.2-2.4; P = .002), as well as discharge to respite care (OR, 2.3; 95% CI, 1.2-4.5; P = .01) and payer status (Medicaid/Medicare compared with commercial OR, 2.0; 95% CI, 1.3-3.0; P = .002) , were identified as risk factors for readmission. Many readmissions may be unavoidable in our current paradigms of care. While medical comorbidities are contributory, a large number of readmissions were not caused by suboptimal medical care or deterioration of medical conditions but by confounding issues of substance abuse or homelessness. Identification of the highest risk cohort for readmission can allow more targeted intervention for similar populations with socially challenged patients.

Hydatidose osseuse de la paroi thoracique : à propos de trois cas

Bone hydatidosis of the chest wall is rarely reported in the literature. Costal and sternal location are uncommon. Through 3 observations and literature review, we report particular pathophysiological and diagnostic aspects of costal and sternal hydatidosis. We also discuss therapeutic and prognostic aspects of this disease. OUR CASES: we report the cases of 45, 41 and 17 years old male patients, 2 of them had previous surgery for thoracic wall mass in general surgery service. Clinical presentation was thoracic wall painful mass sticking to bone. One patient had isolated costal location, the 2 others had sternal location; in one of them, the disease is located in sterno-costo-clavicular area. In all 3 cases, the disease was diagnosed by computed tomography (CT) scan, showing bone lysis or mediastinum enlargement. Patients undergo extended bone resection removing away all destructed parts of the bone. After surgery, albendazole has been prescribed to all patients. No recurrence was observed after 12 months follow-up. Chest wall bone hydatidosis is unusual even in endemic regions, with slow evolution and inconspicuous symptoms. Radiology plays a key role in the management of this disease. Extended surgical resection associated with medical treatment (albendazole) is a reliable treatment without recurrence.

Postoperative persistent hyponatremia: A case with metastatic lung cancer

Introduction: Hyponatremia is most commonly encountered electrolyte disorder in clinical practice. syndrome of inappropriate anti- diuretic hormone secretion (sIADH), most frequent cause of euvolemic hyponatremia, is an important element that increases risk for morbidity and mortality and indicates severity of primary disease. sIADH can be seen in many clinical conditions or as multifactorial. case report: A 64-years old male presented to our facility emergency department with the complaints of shortness of breath and abdominal pain. According to the assessment, Morgagni hernia was in the thoracic and abdominal computed tomography (ct). the patient was hospitalized in the general surgery service and taken to the operation for hernia repair. On day-2 after operation, he had low serum Na+ value (124 mEq/L (124 mmol/L)). serum Na+ value decreased

Time of cholelithiasis' symptom of as a direct risk factor for choledocholitiasis in Federal Ipanema Hospital

Introduction: The purpose is study the outpatients of the Federal Ipanema Hospital (HFI) with symptomatic cholelithiasis who had as choledocholitiasis complication. The HFI, hospital of “Sistema Único de Saúde” (SUS), presents in September 2015 about 800 outpatients with symptomatic cholelithiasis awaiting surgery. The long expect in line, increases the possibility of complications, whereby choledocholitiasis. It is very important stratification of these patients, applying equity. Methods: From January 2014 to August 2015, sixteen patients with choledocholitiasis were selected from the Endoscopy Unit database of HFI and one patient from the General Surgery Service database with surgery diagnosis of choledocholitiasis. It excluded from the group undergoing ERCP prior cholecystectomy patients. Results: Symptom's time of cholelithiasis, age, sex and race of the 17 selected patients were analyzed. 70.58% of patients were aged up to 50 years, 41.17% were male and 58.82% female. The color (self-declaration): 23.52% white, 5.88% black and 47.05% brown. 23.52% were not record in database. The considered symptoms of cholelithiasis were right upper quadrant pain, vomiting and nausea. The average was 267,58 days of symptoms. Conclusion: SUS has difficulties to manage patients with cholelithiasis, without capacitance to operate all within a reasonable time. After analysis, it was found that the cholelithiasis' symptom for more than 200 days is an independent risk factor for choledocholitiasis. It is a important data in order to stratify the patients, operating first whom is at higher risk.

Acute mesenteric ischaemia

Acute mesenteric ischaemia (AMI) is a rare vascular emergency, but one that must be excluded as a cause of acute abdominal pain, especially in older patients, as it has a very high mortality rate. It is a time-critical disease process, and the best outcomes are seen when patients are rapidly diagnosed at the early stage and referred immediately to a hospital with vascular surgery, general surgery and interventional radiology services available. The aim of this article is to cover the diagnosis and management of AMI mainly from a primary care level. The aetio-pathology and clinical presentation of AMI will be described, and particular emphasis will be on how to identify AMI early, the importance of rapid referral, and appropriate approaches to risk factor reduction. There will be a brief discussion on the various secondary care management strategies. However, the main purpose of the article is to better equip GPs to optimally manage AMI in the community and thus improve global AMI outcomes.

A night float week in a surgical clerkship improves student team cohesion

BackgroundWe hypothesize that night float rotations in the third-year surgical clerkship improve student learning and perceptions of team cohesion. MethodsA 1-week night float (NF) system was implemented during the 2013 to 2014 academic year for students. Each student completed 1 week of NF with the Trauma/Emergency General Surgery service. The Perceived Cohesion Scale survey was prospectively administered and National Board of Medical Examiners academic performance retrospectively reviewed. ResultsWe surveyed 70 medical students, 37 traditional call and 33 NF students, with 91% response rate. Perception of team cohesion increased significantly, without perceived loss of educational benefit. Examination scores increased significantly comparing pre- and postintervention groups, with this trend continuing in the following academic year. ConclusionsA week-long student NF experience significantly improved perception of team cohesion and standardized examination results. A dedicated period of NF during the surgical clerkship may improve its overall educational value.

Are Surgeons Being Paid Fairly by Medicaid? A National Comparison of Typical Payments for General Surgeons

Both the Medicare (MCR) and Medicaid (MCD) programs turn 50 this year. Medicare has developed a national resource-based payment methodology for physicians' services, with broad input by specialty societies, and MCD payments are set by individual states by various means. We have conducted the first national comparison of payment methodology of MCD vs MCR for procedures commonly delivered by general surgeons. Using the most recent Centers for Medicare and Medicaid Services' Medicare data for frequency of allowed charges for general surgeons, we selected the most frequently billed procedures and gathered data from the 50 states for MCD and MCR payments. We determined the "Medicaid discount" (MCD payment minus MCR payment) expressed as dollars and percent, as well as dollars paid per relative value of work. We have discovered wide variations in MCD payments among states for the same procedures, demonstrating unexplained "discounts" of MCD payments in relationship to MCR. We found that MCD payments show wide variations across the states, with many states paying far less than MCR for common, essential procedures. These findings call into question the fairness of MCD reimbursement for general surgery services in the United States. This discount to MCR could act as a disincentive for surgeons to care for some patients, based on the state of residence. These unexplained discounts could have considerable long-term effects for patients dependent on the MCD program. Our study should act as a stimulus for states to examine their payment methodologies to provide more uniform and fairer payments for surgical procedures.

Gallbladder Volvulus: A Rare Emergent Cause of Acute Cholecystitis, if Untreated, Progresses to Necrosis and Perforation

Figure 1: The gallbladder (black in color) volvulized on its pedicle is necrotic in appearance. Figure 2: A different angle of the gallbladder with less manipulation reveals the extent of the torsion and the significant pedunculated origin. Figure 3: Ultrasound imaging revealed gallbladder wall thickening of 5 mm and pericholecystic fluid consistent with acute cholecystitis. Figure 4: Computed tomography axial cross section depicts a dilated gallbladder with wall thickening and pericholecystic fluid present. Figure 5: A coronal cross section CT image reveals the extent of the gallbladder dilation and amount of pericholecystic fluid. Case Presentation An 86 year-old woman with a past medical history significant for abdominal hernia and Alzheimer dementia presented to the Emergency Department with a 24 hour history of acute right upper quadrant pain associated with nausea and non-bilious emesis. Physical exam revealed right sided abdominal tenderness with associated mass. All laboratory values were within normal ranges. Both abdominal ultrasound and computed tomography of the abdomen/pelvis revealed a large distended gallbladder with wall thickening and gallstones. Based on presentation and radiologic findings, the emergency general surgery service was consulted for suspected acute cholecystitis. The patient was then admitted for intravenous antibiotics and scheduled for laparoscopic cholecystectomy the following day. Intra-operative findings revealed volvulus with acute necrosis of the entire gallbladder. The gallbladder had a long pedunculated cystic duct and artery that was detorsed before proceeding with resection. Postoperatively, the patient did well and was discharged a few days later tolerating a regular diet. Gallbladder volvulus, a rare occurrence, is the result of a free “floating gallbladder” or gallbladder with a long cystic duct which rotates on its axis [1]. The literature reports approximately 500 cases, with the majority diagnosed intra-operatively [2]. However, current literature suggests that a “typical whirl” sign can diagnose the disease entity through imaging [3]. This torsion, if untreated emergently, has a high mortality rate due to the sequelae of gangrene and perforation. Our case was initially diagnosed based on presentation and radiologic examination as “typical” acute cholecystitis (Figures 1-5). This misdiagnosis triaged our patient into an urgent but not emergent status, and delayed operation 24 hours. In retrospect, we believe that if the patient had presented with signs of sepsis or decompensated after admission, we would have performed an emergent cholecystectomy owing to the complications of gangrene or perforation as high risk for morbidity and mortality [2].

Utilizing Patient Perspectives to Help Reduce Postoperative Readmission Rates

Background: CMS recently began penalizing hospitals for readmissions if they exceeded benchmark rates. While many strategies have been proposed to help minimize readmissions, none have evaluated surgical patients’ perspectives. Study design: All patients with unplanned readmissions within 30 days of discharge from a general surgery service over a three month period were interviewed. Patients admitted to a general surgery service from 2011 - 2012 as identified by the NSQIP database were used as a comparison. Results: A total of 50 patients were enrolled in the study. There were no differences between the study patients and NSQIP patients in terms of age or gender, but there was a significant difference in ASA class (p < 0.01). The majority of patients had a scheduled follow up appointment, however 66% were readmitted before they were able to attend and 6% were readmitted from their postoperative clinic visit. When asked about suggestions to improve discharge planning, 50% were satisfied with the process. Among the other half, 32% suggested improving discharge instructions, 28% advocated for better communication within the care team, 12% felt the discharge process was too long, 12% thought they were discharged too soon, and 8% suggested better communication with family. Conclusions: Understanding the perspectives of surgical patients allows providers to identify targets for quality improvement aimed at reducing readmissions. Using this concept, systems can be developed which target high-risk patients in need of early follow-up, with the ultimate goal of lowering postoperative readmission rates.

Procesos médico-administrativos en Hospitalarios y prolongación de la estancia. Hospital de San José, Bogotá D.C. Colombia

Objective: to describe the medical-administrative factors and family, social and clinical conditions in the internal medicine and general surgery services that influence the prolongation of the stay in the Hospital of San José de Bogotá DC, from January 1 to February 1 2015. Materials and methods: a cross-sectional study, the APGAR, Pfeifer tests and a survey on sociodemographic and clinical variables were applied, the information was obtained from the clinical histories with descriptive statistical analysis and differences by means of Student t, ANOVA and Logistic regression. Results: 470 patients were included, mean age 52 years (SD = 19.0), 52.6% were women; 26.7% presented a prolonged stay of 1.3 days. Cognitive deterioration, infections, cardiovascular pathologies and delays due to lack of medical device were associated with prolonged stay (logistic regression p &lt;0.05). Conclusions: consider prolonged hospital stay as an indicator of quality and tracer of the processes in addition to monitoring it systematically. The direct and indirect costs for the control of resources should be evaluated. Abbreviations: EHP, prolonged hospital stay.

Outcomes in emergency general surgery following the introduction of a consultant-led unit.

Patients presenting with emergency surgical conditions place significant demands on healthcare services globally. The need to improve emergency surgical care has led to establishment of consultant-led emergency surgery units. The aim of this study was to determine the effect of a changed model of service on outcomes. A retrospective observational study of all consecutive emergency general surgical admissions in 2009-2012 was performed. A 2-year time frame before and after the establishment of the emergency general surgery (EGS) service was used to determine the number of admissions and operations, emergency department and hospital length of stay, as well as complication rates. The study included 7233 acute admissions. The EGS service managed 4468 patients (61·6 per cent increase) and performed 1804 operations (41·0 per cent increase). The most common diagnoses during the EGS period included acute appendicitis (532, 11·9 per cent), biliary disease (361, 8·1 per cent) and abdominal pain (561, 12·6 per cent). Appendicectomy (536, 29·7 per cent), cholecystectomy (239, 13·2 per cent) and laparotomy (226, 12·5 per cent) were the most commonly performed procedures. In the EGS period, time in the emergency department was reduced (from 8·0 to 6·0 h; P < 0·001), as was length of hospital stay (from 3·0 to 2·0 days; P < 0·001). The number of complications was reduced by 46·8 per cent, from 172 (6·2 per cent) to 147 (3·3 per cent) (P < 0·001), with a 53 per cent reduction in the number of deaths in the EGS period, from 29 (16·9 per cent) to seven (8 per cent) (P = 0·039). The establishment of a consultant-led emergency surgical service has been associated with improved provision of care, resulting in timely management and improved clinical outcomes.