Surgical Admissions Research Articles

Implementation of a Standardized Tool for Root Cause Analysis Selection.

This study sought to determine if a standardized root cause analysis (RCA2) selection algorithm, developed by the Veterans Affairs, would select high-risk events for RCA. Physician-entered incident reports for all surgical service admissions and perioperative visits were queried over 12 months in the DATIX Clinical Incident Management System. Independent reviewers assigned potential harm and event frequency scores using an institutional scoring system and then calculated and rounded average scores. These were classified using RCA2 terminology (catastrophic, major, moderate, minor for harm; frequent, occasional, uncommon, remote for frequency). The scores were then evaluated with the standardized Safety Assessment Code Matrix (SAC) algorithm from the National Patient Safety Foundation's RCA2 guidelines to determine Potential Harm Scores. The SAC combines severity and probability to determine the necessity of conducting an RCA. Catastrophic and major high-frequency events (matrix score = 3) were classified as "RCA recommended." The study then compared cases selected for RCAs using the updated RCA2 algorithm against cases selected using a current, institutional-specific RCA selection process. One hundred four cases were reviewed, comprising 20 catastrophic, 48 major harm, 26 moderate harm, and 10 minor harm events. After removing 9 high-variance cases, our institution's current selection process selected 18 cases for RCAs, including 6/20 catastrophic, 8/39 major harm, and 4/36 moderate/minor harm events. Only 17.3% of cases had an RCA completed, while the standardized RCA2 algorithm recommended investigation for 56.7% of patient safety events, based on SAC Matrix scoring. Current RCA selection processes rendered 4 RCAs on low potential harm or low-frequency events, while 45 potential high-frequency, high potential harm events did not complete RCAs. Standardizing the selection of patient safety incidents for RCA using the RCA2 algorithm improves case identification based on the event frequency and potential harm score. Thus, this algorithm has the potential to advance patient safety.

Current concepts and targets for preventing the transition of acute to chronic postsurgical pain.

It is estimated that approximately a third of patients undergoing certain surgeries may report some degree of persistent pain postoperatively. Chronic postsurgical pain (CPSP) reduces quality of life, is challenging to treat, and has significant socio-economic impact. From an epidemiological perspective, factors that predispose patients to the development of CPSP may be considered in relation to the patient, the procedure or, the care environment. Prevention or management of transition from acute to chronic pain often need a multidisciplinary approach beginning early in the preoperative period and continuing beyond surgical admission. The current concepts regarding the role of central and peripheral nervous systems in chronification of pain may provide targets for future therapies but, the current evidence seems to suggest that a multimodal analgesic approach of preventive analgesia along with a continued follow-up and treatment after hospital discharge may hold the key to identify and manage the transitioning of acute to chronic pain. A comprehensive multidisciplinary approach with prior identification of risk factors, minimizing the surgical insult and a culture of utilizing multimodal analgesia and continued surveillance beyond the period of hospitalization is an important step towards reducing the development of chronic pain. A transitional pain service model may accomplish many of these goals.

Corrigendum to: Nurse understaffing associated with adverse outcomes for surgical admissions

Corrigendum to: Nurse understaffing associated with adverse outcomes for surgical admissions

Interhospital variability of risk-adjusted mortality rates and associated structural factors in patients undergoing emergency laparotomy: England and Wales population-level analysis.

Emergency surgical admissions represent the majority of general surgical workload. Interhospital variations in outcomes are well recognized. This analysis of a national laparotomy data set compared the best- and worst-performing hospitals according to 30-day mortality and examined differences in process and structural factors. A retrospective multicenter cohort study was performed using data from the England and Wales National Emergency Laparotomy Audit (December 2013 to November 2020). The data set was divided into quintiles based on the risk-adjusted mortality calculated using the National Emergency Laparotomy Audit score risk prediction model. Primary outcome was 30-day mortality. Hospital-level factors were compared across all five quintiles, and logistic regression analysis was conducted comparing the lowest with the highest risk-adjusted mortality quintiles. Risk-adjusted 30-day mortality in the poorest performing quintile was significantly higher than that of the best performing (11.4% vs. 6.6%) despite equivalent predicted mortality (9.4% vs. 9.7%). The best-performing quintile was more likely to be a tertiary surgical (49.5% vs. 37.1%, p < 0.001) or medical school-affiliated center (26.4% vs. 18.0%, p < 0.001). In logistic regression analysis, the strongest associations were for surgery performed in a tertiary center (odds ratio, 0.690 [95% confidence interval, 0.652-0.731], p < 0.001) and if surgery was performed by a gastrointestinal specialist (0.655 [0.626-0.685], p < 0.001). Smaller differences were seen for postoperative intensive care stay (0.848 [0.808-0.890], p < 0.001) and consultant anesthetist involvement (0.900 [0.837-0.967], p = 0.004). This study has identified significant variability in postoperative mortality across hospitals. Structural factors such as gastrointestinal specialist delivered emergency laparotomy and tertiary surgical center status appear to be associated with improved outcomes. Original Research Article; Level II.

WP3.10 - Variability of frailty scoring during unplanned surgical admissions in older persons - why accuracy matters

Abstract Introduction The Clinical Frailty Score (CFS) is a reliable predictor of outcomes for older patients in the acute hospital setting and is used to guide management decisions. Our hospital routinely calculates the CFS for older adults on admission to the Emergency Department (ED). Patients admitted under general surgery will then be referred for a Comprehensive Geriatric Assessment (CGA) by our Perioperative Medicine for the Older Patients undergoing Surgery (POPS) team who also calculate CFS. This study aimed to compare the CFS calculated in ED and CGA for these patients. Methods We performed a single centre prospective study of emergency general surgical admissions who were reviewed as an inpatient by our POPS team between August 2022 and September 2023. CFS from ED documentation was compared to that after CGA. A two tailed, paired t test was performed to compare the CFS on admission and after CGA using GraphPad Prism version 10.0. Results A total of 293 patients were identified with a mean age of 79 years(65-102). There was a difference between the admission CFS [4.2 (3.9-4.4 95%CI)] and the CFS following POPS review [4.5 (4.3-4.7 95%CI)] which was statistically significant (p&amp;lt;0.0001). Univariate analysis showed that CFS was predictive of length of hospital stay. Conclusion CFS calculated in the ED can both over and underestimate the degree of frailty when compared to the CFS calculated during the CGA. As evidence suggests that CFS is predictive of outcomes in this cohort, we suggest staff are adequately trained in undertaking an accurate assessment of this score.

ThP6.7 - Early assessment by a specalist geriatric team reduces length of stay in unplanned surgical admissions

Abstract Intro A comprehensive geriatric assessment (CGA) performed by the Perioperative medicine for Older People undergoing Surgery (POPS) team has been shown to reduce length of stay(LOS) for unplanned hospital admissions in the older population. This study investigates whether timing of POPS review reduces LOS for older adults admitted under the acute general surgical team. Methods We performed a single centre, prospective study of all older adult patients (aged 65 or above) admitted acutely to the general surgical team between August 2022 and September 2023. Timing of POPS review and LOS was calculated, and Mann Whitney-U test was performed. Results Three hundred and nine patients were identified. Of these, 207 patients were reviewed by POPS within 48 hours (early) and 151 of these patients were reviewed within 24 hours (very early) of admission. There was a statistically significant difference (p&amp;lt;0.001) in LOS between those who were assessed by POPS within 48 hours [Median 5 days (IQR 3,9)] versus those beyond 48 hours [Median 9 days (IQR 6,19)]. Very early POPS review (less than 24 hours) resulted in a statistically significant reduction in length of stay compared to POPS review between 24 and 48 hours [Median 5 days (IQR 2,8) versus 6 days (IQR3,9)] p&amp;lt;0.02. Conclusions POPS review within 48 hours reduces length of stay for older patients who have had an acute general surgical admission. Furthermore, this data suggests that very early POPS review (within 24 hours) is associated with a shorter hospital admission. Further research into this will help service planning.

EP51 - Uses of pharmaceutical and mechanical VTE prophylaxis - A clinical audit

Abstract Aim Venous thromboembolism (VTE) is a serious global health care safety concern for both patients and staff. Although it has been amply demonstrated that pharmaceutical and mechanical methods of prophylaxis against VTE are effective, their application has been uneven and insufficient. The purpose of this audit was to assess junior physicians working in general surgery, regarding their adherence to local and NICE guidelines regarding the pharmacological VTE prophylaxis practice as well as the mechanical prophylaxis Methodology Pre-intervention audit took place for two weeks. Throughout the course, it covered every adult general surgical emergency inpatient admission at conquest hospital who were deemed indicated for VTE prophylaxis. Each evening while the patients were still in the hospital, data was collected using the prescription charts, nursing and medical notes. The proforma used for data collection detailed the characteristics of VTE risk, the prophylactic medication prescribed for each patient, TED stockings and whether or not this aligned with the NICE clinical guideline (CG) 46,6.8. Post intervention took place for two weeks after teaching of junior doctors and the same as above was carried out, using the new proforma Results Pre-intervention showed that 87% of patients had the proforma filled in and 100% of patients received the appropriate dose of pharmaceutical prophylaxis. However, less than 40% of patients received the appropriate mechanical prophylaxis. Therefore, intervention was made in the form of a new proforma and teaching to junior. Post intervention data is currently being carried out Conclusion Implementation was necessary to ensure that at-risk patients receive appropriate prophylaxis.

EP588 - Review of the need for Immediate Nasogastric Tube Insertion in patients with Small Bowel Obstruction: Single Centre Quality Improvement Project

Abstract Aim This QIP was conducted in a busy UK hospital. It aims to review, improve, and stress the importance of early insertion of an NG tube in patients who have clinically suspected or radiologically confirmed small bowel obstruction. Method Retrospective data collection involving 72 patients, in a period from Jan to April 2023 (50 patients) and from May to July 2023 (22 patients)Inclusion criteria: adult patients with SBO (clinically suspected or radiologically confirmed) and NGT insertion advised by the surgical teamExclusion criteria: paediatric patients, LBO, and patients not advised NGT in ED Results In the first cycle, we found that NG insertion is delayed 84% &amp;gt; 7 hrs. With associated morbidity of pneumonia, including aspiration in 20% of patients, ileus and sepsis in 8%, and re-admission and mortality in 6%, respectively. The following interventions were carried out. Broad communication with the ED team to highlight the importance of NG insertion for suspected patients. Provide NGT training for ED nursing staff The surgical team and admission nurses should inquire about NGT insertion before accepting patients' admission to surgical emergency wards. Circulating the QIPS recommendation Trust-wide as sharing learning point Post-intervention, we noticed a 50% delay in NGT insertion, which is a huge improvement compared to the 84% delay Conclusion Early insertion of NG for decompression in both pre and post-op periods is known to decrease associated complications, including bowel oedema, perforation, aspiration pneumonia, and post-ileus, leading to better outcomes and a significant decrease in hospital stay length.

FP2.6 - Opportunities for Improvement in Venous Thromboprophylaxis (VTE) of High-Risk Patients Hospitalized for Inflammatory Bowel Disease (IBD) Related Bowel Resection

Abstract Background IBD had a relative risk of 2.2 for VTE compared to the normal population. In May 2020, an international consensus created a statement on VTE prevention in IBD patients. 28days of extended thromboprophylaxis was recommended after discharge only in high risk patients. We aimed to identify high-risk patients for VTE post-IBD-related bowel resection. Methods Retrospective review of 131 patients over 5 years of surgical admissions for IBD-related resection at DGH. Examined factors included patients’ demographics, risk factors for VTE, disease history, and compliance with extended thromboprophylaxis. SPSS22 and Chi-square test were used for analysis. Results The median age was37years.76(58%) were female,74(56.5%) were white-British, Chron’s disease (CD) was98(74.8%), median disease duration was65 months, 101(77.1%) were done laparoscopically, 87(66.4%) were elective, and the median LOS was7days. 5 patients (3.7%) had VTE events. No postoperative stroke happened. DVT and PE were associated with failure of extended thromboprophylaxis prescription (P=0.004,0.000). All VTE events were seen in the 1st 10 days post-discharge. Occurrence of DVT was associated with white-British ethnicity(P=0.000), CD&amp;gt; ulcerative colitis (P=0.001), emergency &amp;gt; elective surgery (P=0.026), bowel anastomosis &amp;gt;stoma formation (P=0.029), ITU admission (P=0.000), Post-operative leak (0.0001), postoperative wound complications(P=0.000). Surgical approach, previous VTE event, and site of diseases weren’t associated with VTE occurrence (P=0.8,0.97,0.94). Conclusion IBD patients are vulnerable to VTE events more than the normal population. Bowel resection in this group of people needs attention for extended VTE prophylaxis, particularly in patients with CD, ITU admission, postoperative leak, and wound complications. These data outline opportunities for improvement, particularly in regard to the extended VTE prophylaxis for 28 days in the before-mentioned high-risk patients.

EP181 - The role of abdominal X-rays in the acute abdomen: a retrospective audit

Abstract Introduction Abdominal x-rays (AXR) are commonly performed as part of the diagnostic work up for acute abdomen despite wide availability of CT. Several studies dispute the role of AXR in acute abdomen, due to low accuracy, uncertain role in diagnosis &amp; management and superiority of CT (1). There are calls to replace AXRs with CT altogether where possible, as patients often end up having CT scans, thereby receiving larger doses of radiation (2). The Royal College of Radiologists (RCR) have produced guidelines to reduce the use of AXR in the acute setting (3). The aim of this audit was to clarify if we adhere to the RCR Guidelines at our DGH. Methods 62 consecutive adult surgical patients admitted to our surgical admissions unit as emergency, between September and November 2023 were included in this retrospective audit. Data was collected regarding patient demographics, reason for request, AXR report, whether patient underwent CT, CT report and time between AXR and CT. Results 97% of AXR requests were compliant with RCR guidelines. 30/62 patients also had a CT scan following initial AXR. Of these, 13 had normal AXR and CT. 9 had normal AXR but abnormal CT. 8 had abnormal AXR which was confirmed on subsequent CT. Discussion We identified that our surgical unit has good compliance with RCR guidelines. However, nearly half of our patients also had a CT scan, in addition to AXR. Although the AXR has lower radiation dose, it may be prudent to restrict the addition of AXR, if a CT is required to assess acute abdomen. We now aim to discuss and propose change in our practice for the future.

ThP6.17 - ‘If it’s not documented, it didn’t happen’: an audit into surgical ward documentation and clinicians expectations in a district general hospital

Abstract Introduction &amp; Aims There are guidelines published by the Royal College of Surgeons (RCS) on adult surgical ward round documentation. Locally, documentation is done on pre populated sheets containing blood results, antibiotics and VTE prophylaxis. We aimed to assess documentation in our unit against the RCS guidelines. Methodology We audited documentation for surgical inpatients over 1 week, looking at daily ward rounds (DWR), and initial consultant post take ward round (PTWR). Through an online survey, we established the minimum standards of documentation expected by doctors of varying seniority on a ward round within our unit. Results 21 DWR and 21 PTWR entries were reviewed; 90% (n=19) contained the date and 95% (n=20) the name of the reviewing consultant. Time of review was documented in 29% (n=6) and 35% (n=7) respectively. 33% (n=4) DWR entries documented examination findings, compared to 8 40% (n=8) PTWR entries. 45% (n=10) PTWR contained the presenting complaint. 26 doctors completed the online survey; 100% thought date, time and examination findings were important. More senior doctors highlighted that drain status was a key part of ward round documentation. Conclusions Within our unit, there is poor adherence with the RCS ward round documentation guidelines. Juniors suggested this is because ward rounds are too fast paced, often on complex and comorbid patients. We plan to address our findings with an improved surgical admission proforma and an electronic handover to ensure all team members are up to date with patients’ admission details.

ThP5.11 - Reducing Gallstone Related Patient Episodes Through Index Admission Management: A Multicentre Retrospective Study

Abstract Aim Gallstones represent a significant portion of acute general surgical admissions, with widespread management practices across the UK. Our objective was to assess the effects of implementing proactive management strategies for symptomatic gallstones and their complications on admissions related to gallstone. Methods A retrospective multicentre study of three acute general surgical units within a single health board with similar population coverage between 2014 and 2018. In site A, the standard of care was definitive management of gallstone disease in the index admission; whereas in site B &amp; C this was not the case. All gallstone related presentations were included. The data was extracted from the health board coding data. Number of biliary related admissions compared between the three sites. Results 3,790 episodes were identified. Biliary colic was the most common (54.9%) reason for presentation followed by acute cholecystitis (22.7%), acute pancreatitis (16.2%) and ascending cholangitis (6.2%). For biliary colic: site A had 361 presentations, site B had 853 presentations and site C had 867 presentations. The occurrences of more than one admission were 22.7%, 36.3%, and 42.3% for Site A, B, and C, respectively. Overall, site A had 796 biliary presentations; compared to 1497 each at site B and C. Conclusion Implementing definitive surgical interventions during the index admission for biliary-related cases offers a substantial reduction in re-admission rates, leading to an overall decrease in hospital attendance. This not only yields significant cost benefits for the health board but also enhances the quality of life for patients.

SP2.8 - The undifferentiated general surgical take over 10 years: emergency operating

Abstract Aims The aim of this study is to further understand the specific pressures on the department’s operating theatres and capacity, and to identify areas in which we could adapt to facilitate these demands, by reviewing the undifferentiated general surgical admissions in a District General Hospital in July 2013 and July 2023. Methods All patients seen by the emergency general surgical team in July 2013 and July 2023 were identified retrospectively. Data was gathered using electronic notes, to analyse admissions and surgeries within 30 days. Patients were excluded if there was insufficient information available. Results 26% (n=102/395) of all patients treated by emergency general surgical teams in July 2013 had surgery within 30 days. This proportion reduced to 23% (134/594) in July 2023, however overall volume has increased by 31%. The proportion of procedures performed on the day of admission has decreased from 10% to 7%. 3% of procedures were performed under local anaesthetic both in 2013 and 2023. Wait from admission to surgery has decreased from 2.84 days (+/-0.6, p=0.02) in 2013, to 1.9 days in 2023 (+/-0.83, p=0.02). Conclusions Although volume of procedures within the same 31-day period has increased throughout the 10 years, the proportion of patients that proceed to intervention has reduced marginally. This is reflected in the increasingly busy emergency operating lists throughout the country, with little change in resources to account for increasing volume. The rising proportion of patients managed conservatively may represent improving medical management of conditions, or more pragmatic management of frail patients.

WP3.5 - Laparoscopic cholecystectomy: analysis of indications, time to surgery (TTS) and complications

Abstract Aims Our aims are to establish whether current waiting times for cholecystectomy in our local trust between 01/2021 and 01/2022 are in line with NICE guidelines and compare with average national waiting times. We aim to establish the indications for cholecystectomy (CBD stones, cholecystitis, biliary colic, pancreatitis) and compare waiting times and readmission rates during the waiting period; estimate the rate of conversion to open/subtotal cholecystectomy and any subsequent complications. Methods Data collection and analysis for the period of 01/2021 – 01/2022: average waiting times, rate of conversion, indications, complications. Results 269 patients were analysed after exclusions. Of these, mean waiting time from booking to TTS for uncomplicated biliary colic was 63.26 days. The median TTS from booking was 14 days for hot gallbladders. Of patients diagnosed as biliary colic, the TTS following an acute hospital admission was 63.26 days. Similarly, the patients referred via GP to the outpatient surgical clinic for the same diagnosis was 78.88 days. 5 patients who were referred routinely via GP to the outpatient surgical clinic had complications requiring an acute surgical admission during the waiting period. The rate of conversion to open was 0% during the 1-year period. 2 patients had subtotal cholecystectomies, one of which had persistent bile leak managed with drains and subsequent ERCP. Conclusion The median TTS for hot gallbladder is in line with national standard. There is a tendency to opt for subtotal cholecystectomy as bail out as compared to the previous years.

SP2.6 - Improvements in patient discharge efficiency and safety: the impact of a dedicated Clinical Pharmacist in an Emergency General Surgery team

Abstract Introduction Efficiency in management of acute surgical admissions is related to safe clinical practice combined with good patient flow, optimising use of limited capacity. Preventable morbidity and discharge delays may significantly compromise outcomes for Emergency General Surgery (EGS) teams managing increasing numbers of admissions. Aim To investigate the effectiveness of a prescribing pharmacist employed within an EGS team in a DGH, with specific focus on patient discharge times by facilitating discharge prescription efficiency, including venous thromboembolism (VTE) prophylaxis. Methods Data was collected for two separate 1-month time periods in 2021 (Period A), before the appointment of a pharmacist and in 2023 (Period B), after pharmacist appointment. Data was analysed for (i) differences in times related to ‘to take home’ (TTH) medication prescription and (ii) prescribing of post-operative extended enoxaparin prophylaxis (EEP) following discharge. Results Mean time for prescription of TTH medications during working hours in Period A was 100 minutes (n=133, range 0-433 minutes) compared with 67 minutes (n=120, range 0-416 minutes) in Period B. Pharmacist prescribing accounted for 51.6% of TTH prescriptions with a mean prescription time of 18.6 minutes (range 0-389 minutes). During Period A, 36% of patients (n=48) who had a VTE assessment mandating EEP received this on discharge compared to 100% in Period B (n=31). Conclusions This data highlights an improvement in prescribing of TTH medications since appointment of a dedicated EGS pharmacist. The consequences of such improvements include more rapid patient flow, better patient experience and heightened patient safety by prevention of post-operative VTE through EEP.

Association between surgical admissions, cognition, and neurodegeneration in older people: a population-based study from the UK Biobank

Previous studies have shown that major surgical and medical hospital admissions are associated with cognitive decline in older people (aged 40-69years at recruitment), which is concerning for patients and caregivers. We aimed to validate these findings in a large cohort and investigate associations with neurodegeneration using MRI. For this population-based study, we analysed data from the UK Biobank collected from March 13, 2006, to July 16, 2023, linked to the National Health Service Hospital Episode Statistics database, excluding participants with dementia diagnoses. We constructed fully adjusted models that included age, time, sex, Lancet Commission dementia risk factors, stroke, and hospital admissions with a participant random effect. Primary outcomes were hippocampal volume and white matter hyperintensities, both of which are established markers of neurodegeneration, and exploratory analyses investigated the cortical thickness of Desikan-Killiany-Tourville atlas regions. The main cognitive outcomes were reaction time, fluid intelligence, and prospective and numeric memory. Surgeries were calculated cumulatively starting from 8years before the baseline evaluation. Of 502 412participants in the UK Biobank study, 492 802participants were eligible for inclusion in this study, of whom 46 706underwent MRI. Small adverse associations with cognition were found per surgery: reaction time increased by 0·273ms, fluid intelligence score decreased by 0·057correct responses, prospective memory (scored as correct at first attempt) decreased (odds ratio 0·96 [95% CI 0·95to 0·97]), and numeric memory maximum correct matches decreased by 0·025in fully adjusted models. Surgeries were associated with smaller hippocampal volume (β=-5·76mm³ [-7·89to-3·64]) and greater white matter hyperintensities volume (β=100·02 mm³ [66·17to 133·87]) in fully adjusted models. Surgeries were also associated with neurodegeneration of the insula and superior temporal cortex. This population-based study corroborates that surgeries are generally safe but cumulatively are associated with cognitive decline and neurodegeneration. Perioperative brain health should be prioritised for older and vulnerable patients, particularly those who have multiple surgical procedures. The Australian and New Zealand College of Anaesthetists (ANZCA) Foundation and the University of Sydney.

Nurse understaffing associated with adverse outcomes for surgical admissions.

Nurses play a crucial role in maintaining the safety of surgical patients. Few nurse staffing studies have looked specifically at surgical patients to examine the impact of exposure to low staffing on patient outcomes. A longitudinal patient analysis was conducted in four organizations in England using routine data from 213 910 admissions to all surgical specialties. Patients' staffing exposures were modelled as counts of understaffed registered nurse and nurse assistant days in the first 5 inpatient days. Understaffing was identified when staffing per patient-day was below the mean for the ward. Cox models were used to examine mortality within 30 days of admission and readmission within 30 days of discharge. Generalized linear models were used to investigate duration of hospital stay and occurrence of hospital-acquired conditions. Increased exposure to registered nurse understaffing was associated with longer hospital stay and increased risk of deep vein thrombosis, pneumonia, and pressure ulcers. This was also true for nurse assistant understaffing, but the effect sizes tended to be smaller. In the Cox models, there were similarly increased hazards of death for registered nurse understaffing (HR 1.09, 95% c.i. 1.07 to 1.12) and nurse assistant understaffing (HR 1.10, 1.08 to 1.13), whereas the effect size of registered nurse understaffing for readmission (HR 1.02, 1.02 to 1.03) was greater than that seen with nurse assistants (HR 1.01, 1.01 to 1.02). Understaffing by both registered nurses and nursing assistants is associated with increased risks of a range of adverse events, and generally larger effects are seen with registered nurse understaffing.

Neonatal surgical mortality at a low resource setting, HEAL Africa tertiary hospital, Eastern Democratic Republic of the Congo.

This study describes the experience with common neonatal surgical conditions and their outcomes at a single center in the Eastern Democratic Republic of the Congo (DRC) over a period of 7years (2016-2022). A retrospective review of neonatal surgical admissions and their outcomes was performed for patient admitted between January 2016 and December 2022 at HEAL Africa teaching hospital. Data were collected from the neonatal admission and discharge registry for all patients with a potential surgical condition. 107 neonates potentially requiring surgery were identified. 81.3% were referred from facilities within 10km of HEAL Africa. The most common diagnosis was myelomeningocele/meningocele (27.1%). 68.2% of patients had an operation. The overall mortality was 29% for all patients and mean length of stay 9.9days. Operated patients had a lower mortality at 16.4% (p-value < 0.001, OR 0.155, CI 0.062-0.389) while patients with a birth weight of less than 2500g were more likely to die (p-value < 0.001, OR 5.333, CI 2.062-13.79). The neonatal mortality rate for patients presenting with a potential surgical condition is extremely high. This is multifactorial and largely related to patient selection inherent to resource limitations.

Patterns and Outcomes of Opioid Use Before and After Hospitalization for Critical Illness: A Population-Based Cohort Study.

Background: Hospitalization represents a major access point for prescription opioids, yet little is known regarding patterns and outcomes of opioid exposures before and after hospitalization for critical illness. Methods: This is an observational, population-based cohort study of adults (≥18 years) hospitalized for critical illness from 2010 to 2019. Multivariable models assess associations between opioid exposures prior to hospitalization, classified according to the Consortium to Study Opioid Risks and Trends, and posthospitalization opioid exposures and clinical outcomes through 1-year posthospitalization. Results: Of 11 496 patients, 6318 (55%) were men with a median age of 66 (51, 79) years and 40% (n = 4623) surgical admissions. Prehospitalization opioid availability included 8449 (73%) none, 2117 (18%) short-term, 471 (4%) episodic, and 459 (4%) long-term. Thirty-nine percent (4144/10 708) of hospital survivors were discharged with opioids, with higher prescribing rates for surgical admissions (55%). Greater preadmission opioid exposures were associated with higher prevalent opioid availability at 1 year (odds ratio [95% confidence interval] 24.1 [18.3-31.8], 9.42 [7.18-12.3], and 2.55 [2.08-3.12] for long-term, episodic, and short-term exposures, respectively, vs none, P < .001). Greater preadmission opioid exposures were associated with longer hospitalizations (1.13 [1.04-1.23], 1.15 [1.06-1.25], and 1.08 [1.04-1.13] multiplicative increase in geometric mean, P < .001), more readmissions (hazard ratio [HR] 2.08 [1.74-2.49], 1.88 [1.56-2.26], and 1.48 [1.33-1.64], P < .001), and higher 1-year mortality (HR 1.59 [1.28-1.98], 1.75 [1.41-2.18], and 1.49 [1.32-1.69], P < .001). Similar associations were observed across surgical and nonsurgical admissions. Conclusions: Prehospitalization opioid exposures in survivors of critical illness are associated with clinical outcomes through 1 year and may serve as important prognostic markers.

If the peri-operative patient pathway was right, what would it look like?

Patients undergoing surgery deserve the best possible peri-operative outcomes. Each stage of the peri-operative patient journey offers opportunities to improve care delivery, with shorter lengths of stay, less complications, reduced costs and better value. These opportunities were identified through narrative review of the literature, with consultation and consensus at the hidden pandemic (of postoperative complications) summit 2, July 2023 in Adelaide, Australia RESULTS: Before surgery: Some patients who receive timely alternative treatments may not need surgery at all. The period of waiting after listing should be a time of preparation. Risk assessment at the time of surgical listing facilitates recognition of need for comorbidity optimisation and identifies those who will most benefit from prehabilitation, particularly frail and deconditioned patients. During the surgical admission, ERAS programs result in less postoperative complications, shorter length of stay and better patient experience but require agreement between clinicians, and coordinated monitoring of delivery of the elements in the ERAS bundle of care. At-risk patients need to have the appropriate levels of monitoring for cardiovascular instability, renal impairment or respiratory dysfunction, to facilitate timely, proactive management if they develop. Access to allied health in the early postoperative period is also critical for promoting mobility, and earlier discharge, particularly after joint surgery. Where appropriate, provision of rehabilitation services at home improves patient experience and adds value. The peri-operative patient journey begins and ends with primary care so there is a need for clear communication, documentation, around sharing of responsibility between practitioners at each stage. Identifying and mitigating risk to reduce complications and length of stay in hospital will improve outcomes for patients and deliver the best value for the health system.