Single-site Review Research Articles

Outcomes of Emergency Surgical patients with acute pathology managed without emergency laparotomy - a single site review

Abstract Aim To establish the outcomes of Emergency General Surgery patients admitted with acute pathology that did not progress to Emergency Laparotomy Method Retrospective single site review of all Emergency General Surgery patients admitted over three calendar months. Review of patient demographics, diagnostics, diagnosis and management. Identification of and further collection of data from electronic patient records for patients that did not proceed to Emergency Laparotomy despite indicative pathology. Results A total of 619 emergency general surgical patients were admitted from 1st January to 31st March 2023. 39 (6.3%) patients had an Emergency Laparotomy. 17 (2.7%) patients did not proceed to laparotomy despite pathology that could indicate the need for emergency laparotomy. 100% of these patients has CT imaging to diagnose the pathology. Of the 17 patients without laparotomy 12 were female patients. Median age of 86 years (range 42 – 91 years). At 30 days post admission 6 patients who did not proceed to laparotomy were alive. 7 patients survived to discharge, 5 were discharged home and 2 were discharged to a Nursing Home for full nursing care requirements. Conclusion Surgeons are starting to explore the issues around futility in emergency general surgery. This snapshot retrospective review shows alignment with the very limited published literature. We recognise our numbers are extremely limited. Further data collection and analysis is needed to explore futility in emergency general surgery.

664 “Minimally Invasive” Skin Grafting with Enzymatic Debridement and Autologous Skin Cell Spray

Abstract Introduction Minimally invasive surgery is increasingly becoming standard of care across numerous subspecialties. However, burn surgery has lagged behind; as the mainstay of reconstruction still involves wound excision with a knife, a commensurately sized skin graft, and a painful donor site. In recent years, several new technologies have the potential to be used synergistically to perform “minimally invasive” skin grafts. Enzymatic debridement with bromelain and autologous skin cell spray (ASCS) have independently been shown to reduce the need for split-thickness skin graft (STSG) and decrease the donor site size when grafting is performed. Bromelain is more likely to preserve healthy dermis and ASCS allows an 80:1 expansion. Due to constraints regarding the temporal course of these products only being available via studies before one was FDA approved, these two therapies have not been utilized together in the US until recently. A paucity of literature regarding their use in combination currently exists. Methods This study is a single site review of patients treated the continued access study protocol for bromelain-based enzymatic debridement and with ASCS per the FDA-approved instructions for use. Enzymatic debridement was performed over a 4-hour period with appropriate analgesia. Deep partial-thickness burns with residual dermis were treated with ASCS after enzymatic debridement and superficial dermabrasion. Wounds were dressed with a small pore non-adherent film and layered gauze. Full-thickness burn injuries were treated with conventional STSG. Results Two patients were treated over a 2 week period. One was a 51 yr old male with 17% TBSA superficial and deep partial thickness flame burns, of which 11% were deemed deep enough to warrant treatment with enzymatic debridement. 15% TBSA was treated with ASCS including the arms, back, and posterior neck with a 24 sq cm donor site. Wound closure was noted post-operative day 7 with complete re-epithelialization. The second patient was a 21-year-old male with several comorbidities impairing wound healing (diabetes [HgbA1c of 9.9], scurvy, and zinc deficiency. He had deep-partial and full-thickness burns to bilateral feet. The dorsum of the right foot was reconstructed with ASCS only and a 6 sq cm donor site, and the left foot was treated with a 3:1 meshed STSG and ASCS overspray with 100% take. Conclusions Enzymatic debridement and ASCS can be utilized to treat deep partial-thickness burns with a “minimally invasive” reconstruction. The donor sites in both patients were much smaller than had they been treated with a conventional meshed STSG. Further study is needed to determine which subsets of patients and burn wound characteristics are optimal for this combination of technologies. More data regarding outcomes such as length of stay, costs, and scar formation compared to standard of care is also warranted.

Abstract P829: Bi-Directional Quality Review in a Large Telestroke Network: Improving Stroke Care Through Mutual Learning

Introduction: Our hub and spoke telestroke (TS) network consists of 26 sites across 6 states, with >1000 consults/year. Without a shared EMR, patient outcomes are often unknown. We aimed to improve communication of patient outcomes and patient care by implementing multi-disciplinary quality review across multiple health systems. Methods: To determine interest in and format of the review, we first conducted interviews with coordinators from 3 highly engaged sites of varying sizes and capabilities. We had strong consensus that a bi-directional quality review would be helpful and that group-based discussion was preferred over single site review. Coordinators chose review flags of long process metrics, missed treatments, thrombectomies, complications, and mortalities with sentinel events reviewed immediately, off-cycle. A case review sheet is uploaded to HIPAA-compliant Box drive and neuroimaging to PACS. Hub and spoke present cases over Zoom using standard SOAR format: Situation, Outcome, Assessment, Recommendation. The group grades each case as standard of care (SOC) met, exceeded, or not met, +/- opportunities for improvement (OFI). Discussion includes recommendations to the individual hospital or network. Results: From 4/2019-7/2020, we conducted 8 bi-directional case reviews of 21 TS cases with 9 spokes (mean 4.3 spokes/review, range 2-6). Of 47 spoke participants, 43% were stroke coordinators, 34% were ED managers, with rare hospitalists present. Hub participants were 8 vascular neurologists/fellows and 3 TS coordinators/managers. Case content was 33% recognition, 49% acute treatment, and 19% disposition. SOC was rated as met or exceeded in 86% of cases with OFI noted in 100%. The Table details discussion themes. Conclusion: A bi-directional quality review can share knowledge and best practices across a large TS network, improving inter-facility communication and site engagement. We hope next to increase physician attendance and engage more sites.

Assessing outcomes in hip fracture patients under the age of 60.

Hip fractures are a common and serious orthopaedic injury. The principle of treatment for hip fractures in the "non-elderly" patient is to preserve the native hip. There is limited published literature in this area. The aim of this research is to review all of the "non-elderly" hip fracture patients to report on the demographics, fracture patterns, fixation types, and revisions. This was a retrospective single-site review of all of the "non-elderly" patients who underwent operative management for hip fractures between 1999 and 2019. A manual review was done of all of the x-rays for the identified patients to confirm the fracture type and identify further surgeries. Three hundred and eighty-one patients were identified. The average age was 48.4years old. Two hundred and thirty nine of them were intra-capsular, and 142 of them were extra-capsular fractures. Dynamic hip screw (DHS) was the most popular fixation method. In the recent decade of data, the number of hemi-arthroplasties remained consistent, but the number of total hip arthroplasties (THAs) performed increased sevenfold. Mean follow-up was 35months. Forty-three (11%) patients required follow-up surgery. Non-union accounted for 56% of all revisions and avascular necrosis for 19%. THA was performed in 70% of all revisions. DHS remains the most widely used fixation technique in an effort to preserve the native hip. The use of THA has increased and surpassed the usage of hemi-arthroplasty in recent times. A high proportion of these patients will go on to develop complications requiring secondary surgery; therefore, they all need long-term follow-up.

Urolithiasis in Pediatric Patients: A Single Center Study of Incidence, Clinical Presentation and Outcome

The incidence of kidney stones in adults has increased in the last 30 years. This retrospective, single site review was done to test the hypotheses that the incidence of urolithiasis in pediatric patients increased from 1994 to 2005, and that metabolic abnormalities were more common in patients with renal stones in the final 3 years of the study period. Charts from 2 time periods were reviewed, 1994 to 1996 (period 1) and 2003 to 2005 (period 2). Clinical and laboratory data, including demographics, presenting complaints, laboratory assessment, treatment and outcome, were tabulated in patients with confirmed urolithiasis. The number of patients with urolithiasis increased from 7 in period 1 to 61 in period 2. When expressed as cases per 100 new patients the incidence increased 4.6 times (p = 0.014). Focusing on period 2, 28% of patients were younger than 10 years. While blood tests were generally normal, 76% of patients had at least 1 abnormality in the 24-hour urine collection. Hypocitraturia, which was the most common metabolic abnormality, was noted in 52% of patients. The small number of patients in period 1 precluded determination as to whether metabolic abnormalities were more common in period 2. Surgery and/or lithotripsy was required in 12 children. Stone disease recurred in 39% of the patients. The incidence of urolithiasis in the pediatric population increased nearly 5-fold at our institution during the last decade. We recommend that the primary diagnostic test be a 24-hour urine collection. The most common metabolic abnormality was hypocitraturia, followed by hypercalciuria. Recurrence of stones is common (approximately 40% rate) and followup is advised.