59 Improving the Identification and Management of Delirium in Older Surgical Patients

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
C L Baguneid ◽  
K L Millington ◽  
J Pattinson ◽  
G Ogden ◽  
F Malcolm ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Clinical History ◽  
Screening Tools ◽  
Emergency Laparotomy ◽  
True Prevalence ◽  
Nurse Consultant ◽  
Training Materials ◽  
Pdsa Cycle ◽  
High Incidence ◽  
Surgical Pathway

Abstract Local Problem A multidisciplinary team comprising a consultant geriatrician and nurse consultant reviews all patients aged ≥70 years who have an emergency laparotomy at Royal Derby Hospital. Anecdotally there is a high incidence of delirium but retrospective casenote audit found only 19% of patients admitted for emergency laparotomy July 2018–July 2019 were identified as having delirium by the surgical team. Method A first PDSA cycle showed that the 4AT was feasible for use by healthcare assistants on the surgical assessment unit (SAU). A second PDSA cycle, described here, sought to develop a rationale for implementation of the 4AT as part of surgical assessment by comparing true prevalence of delirium using 4AT, with the prevalence detected using methods currently mandated by our hospital. All patients aged ≥65 years admitted as part of the surgical pathway had 4AT completed by a member of our improvement team on admission, with daily review until discharge. Results Data were collected for 111 consecutive emergency surgical admissions. Mean (SD) age was 78.3 (7.7) years. Of these, 1 and 3 were categorised as having delirium and dementia respectively using existing hospital screening tools. Using 4AT, 36 (32%) of patients were identified as having delirium. When supplemented by clinical history, true prevalence was 40 (36%). Average (SD) length of stay was 7 (5.6) days for the whole cohort, 10 (6.5) and 5.3 (4.3) days for those with and without delirium respectively. Conclusions 4AT was 92% sensitive for delirium in our cohort. The existing hospital tool was underutilised to the point of being useless. Patients with delirium had a longer length of stay. We have developed a modified 4AT paper tool and training materials and are now piloting routine use in SAU.

scholarly journals O33: PROSPECTIVE RISK ASSESSMENT ALONE DOES NOT IMPROVE 30-DAY MORTALITY IN EMERGENCY LAPAROTOMY PATIENTS

2021 ◽  
Vol 108 (Supplement_1) ◽  
Author(s):  
S Vavilov ◽  
P Pockney
Keyword(s):  
Risk Assessment ◽  
Length Of Stay ◽  
New England ◽  
Favourable Effect ◽  
Mortality Data ◽  
Emergency Laparotomy ◽  
Icu Length Of Stay ◽  
Possum Score ◽  
Prospective Risk ◽  
American Society

Abstract Introduction Emergency laparotomy still carries a high mortality risk. According to the latest National Emergency Laparotomy Audit (NELA) report, half of the patients without pre-operative risk scoring had a higher observed than predicted mortality. Data from Perth, Australia also suggests that pre-operative scoring improves mortality. The aim of this study was to determine if a prospective risk assessment has an independent favourable effect on outcomes. Method A retrospective review of all emergency abdominal surgeries meeting NELA inclusion criteria undertaken at four different-sized Australian surgical centres was performed between April 2015 and December 2018. A predicted and observed mortality was assessed in prospectively and retrospectively risk-stratified patients. Result There were 852 patients charts reviewed during the study period. Patient demographics included 404 males (47.4%), mean age: 69 years, median American Society of Anaesthesiologists score: 3, mean length of stay: 14.0 days and mean ICU length of stay: 1.8 days. There were 72 patients who died within 30 days (8.5%). Median preoperative P-POSSUM score was 6.9%, median preoperative NELA score – 5.2%. A total of 27/133 (20.3%) patients who were scored prospectively died within 30 days; 45/719 (6.3%) retrospectively scored patients died within 30 days. Neither of these rates was very different from the predicted. Conclusion 30-day mortality in emergency laparotomy patients in Hunter New England region, Australia, compares favourably with the latest mortality figures reported by NELA. However, contrary to other publications, prospective scoring alone did not have any beneficial effect on 30-day mortality in our cohort Take-home message Patients undergoing emergency abdominal surgery require preoperative risk assessment to improve outcomes. However, just the fact of assigning a risk score preoperatively alone does not help to improve mortality.

Reducing length of stay for patients with acute myeloid leukemia receiving inpatient high-dose cytarabine consolidation chemotherapy.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 257-257
Author(s):  
Caroline Jones ◽  
David Riley ◽  
Amy Morris ◽  
Jeremy Michael Sen ◽  
Alana Ferrari ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Multidisciplinary Team ◽  
Medication Reconciliation ◽  
Standard Treatment ◽  
Treatment Time ◽  
Action Plan ◽  
High Dose ◽  
Pdsa Cycle ◽  
High Dose Cytarabine ◽  
Ideal Process

257 Background: For patients receiving high dose cytarabine (HiDAC) at University of Virginia (UVA) Health between 10/2019 and 10/2020, median length of stay (LOS) from time of clinic appointment to hospital discharge was 119.35 hours. Standard treatment time should be 112 hours from premedication to end of chemotherapy. There are no national standards for duration of inpatient stay for planned chemotherapy, but only 50% of these patients were discharged after noon (over 3 hours post-chemotherapy completion). LOS that extends beyond the standard treatment time results in increased cost, overutilization of hospital resources, delayed admissions for future patients, and patient dissatisfaction. Methods: A multidisciplinary team comprised of licensed providers, pharmacists, and nurses was formed. The team focused on percentage of patients discharged by noon as a surrogate marker for LOS due to inconsistency of admission times; the aim was to increase patients discharged by noon to 65%. Reviewing the baseline data revealed an unstable process with a 3-sigma X-bar statistical process control chart. The team developed current and ideal process state maps, a Pareto chart, and a priority matrix to determine an action plan. The most common identified causes for delay in discharge included: lack of standardized discharge checklist, discharge order placed after 10 am, medications dispensed from the outpatient pharmacy after 11 am, licensed providers not prioritizing discharge patients, and medication reconciliation not completed prior to day of discharge. Results: From 10/2020 to 5/2021, the first PDSA cycle focused on standardizing the discharge process to correct the instability in the process. A discharge checklist was created based on the ideal process map, which allowed the providers to have a consistent process at discharge. 3-sigma Xbar chart demonstrated a now stable process and an increase of patients discharged by noon to 58%. During the second PDSA cycle starting in 6/2021, providers completed medication reconciliation the day before discharge, prioritized HiDAC discharges first during rounds, and ensured discharge orders were placed by completion of the last chemotherapy bag. Data collection is ongoing, and will be analyzed by August 2021. Future tests of change are planned to focus on the pharmacy medication delivery service. Hospital LOS has also decreased after the first PDSA cycle. Conclusions: Using quality improvement methodology, a multidisciplinary team developed an action plan for patients receiving HiDAC which to date has increased the percentage of patients discharging by noon and decreased length of stay. This outcome may lead to reduce hospitalization costs and increase bed availability for other oncology patients. Further PDSA cycles are scheduled and continuous evaluation of the process is ongoing.

scholarly journals Pattern and Presentation of Prostate Cancer at a Referral Centre in the Brong Ahafo Region of Ghana; A 10-Year Retrospective Study

2020 ◽  
Vol 5 (1) ◽  
Keyword(s):  
Public Health ◽  
Prostate Cancer ◽  
Perineural Invasion ◽  
Specific Antigen ◽  
Digital Rectal Examination ◽  
Screening Tools ◽  
High Incidence ◽  
Prostate Diseases ◽  
Brong Ahafo Region ◽  
Brong Ahafo

Introduction: Prostate cancer is gradually reaching a very high incidence in Africa, especially in the Sub-Saharan region. Understanding the dynamics in occurrence of the disorder is one approach to developing effective public health programmes and interventions that will help curb the rising incidence. Objective: This study was aimed at providing comprehensive and credible data on prostate cancer by assessing the incidence, trend and presentation in the Brong Ahafo Region of Ghana. We sought to provide region-specific hardcore data that will help to assess the issue and provide remedies. Methodology: All prostate disease cases recorded from the year 2009 to 2018 were retrospectively reviewed. Subjects from 40 years and above were eligible for screening. Diagnostic and screening tools for prostate cancer at the study site include family history, serum prostate specific antigen (PSA) test, digital rectal examination, urological ultrasound scan and histopathology (biopsy). Age, PSA values and year of screening/diagnosis were also retrieved from patient folders for the study. Histological findings and parameters considered in the study included diagnosis, carcinoma grading, perineural invasion (PNI) and percentage of affected tissues (%TA). Results: Prostate cancer cases were 369, representing 36.4% of the 1,014 prostate diseases studied. The highest annual incidence was recorded in 2014 with 51 cases (13.8%). The ages of patients ranged from 46 to 101 years with a modal age range of 70 - 79 years and a mean ± SD of 72.2 ± 9.8. The mean PSA value recorded was 37.1ng/ml (±107.3) with predominance in the 11 - 20.9 ng/ml range. Majority of Group Grade 2-5 (79%) constituted progressive prostate cancer. There was no significant correlation (p = 0.091) between grade of prostate cancer and perineural invasion. Conclusion: There is a high incidence of prostate cancer in the Brong Ahafo Region of Ghana (32 per 100,000), predominantly advanced prostatic carcinoma. Reported cases also show high %TA (38.7%) and PNI (38.0%). Early screening for prostate diseases should be encouraged to avoid progression to advanced stage and public health interventions are needed to address some of these issues.

The Small Blue Cell Dilemma Associated With Tamoxifen Therapy

2001 ◽  
Vol 125 (8) ◽  
pp. 1047-1050 ◽  
Author(s):  
Yi Jun Yang ◽  
Linda K. Trapkin ◽  
Roberta K. Demoski ◽  
Jeannette Bellerdine ◽  
Celeste N. Powers
Keyword(s):  
Older Patients ◽  
Endometrial Hyperplasia ◽  
Clinical History ◽  
Tamoxifen Therapy ◽  
Tamoxifen Treatment ◽  
Endometrial Polyps ◽  
High Incidence ◽  
History Of ◽  
Blue Cell

Abstract Context.—Several endometrial diseases, such as endometrial hyperplasia, endometrial carcinoma, and endometrial polyps, have been reported to be associated with tamoxifen administration. We recently observed a high incidence of distinctive small blue cells in Papanicolaou tests of women who had received tamoxifen treatment for breast carcinoma. Objectives.—To define the characteristics of these small blue cells, to identify the patient population in which they are found, and to determine the clinical significance and possible etiology of these findings. Design.—A total of 154 Papanicolaou tests from 60 patients with a clinical history of tamoxifen therapy were reviewed retrospectively. Results.—Small blue cells were found in 40% of Papanicolaou tests from patients who received tamoxifen therapy. Patients with small blue cells in their Papanicolaou tests were an average of 9 years older at the time tamoxifen therapy was initiated than those without. Among the available follow-up surgical biopsies, no malignant diagnoses were made. Conclusions.—We conclude that these distinctive small blue cells are found more frequently in older patients and most probably represent proliferative reserve cells of cervical/vaginal epithelium resulting from the estrogenic agonist effect of tamoxifen. More importantly, they are nonneoplastic in nature.

Delirium, Confusion, and Agitation

2019 ◽  
pp. 319-329
Author(s):  
Wendy Goldberg ◽  
Greg Mahr ◽  
Amy M. Williams ◽  
Michael Ryan
Keyword(s):  
Length Of Stay ◽  
Medical Care ◽  
Caregiver Burden ◽  
Terminally Ill ◽  
Cost Of Care ◽  
Screening Tools ◽  
Medical Complications ◽  
Common Complication ◽  
Nursing Management ◽  
Complex Disorder

Delirium is a serious and common complication of the medical care of the seriously or terminally ill. Patients present as confused, agitated, abstracted, or withdrawn. Delirium, though challenging to diagnose, is important to recognize and treat. Medical complications, length of stay, cost of care, and caregiver burden are all adversely affected by the presence of delirium. The authors review diagnostic issues, including commonly used screening tools. Pharmacological and nonpharmacological interventions are described in detail. Such interventions have been shown to both prevent and effectively treat delirium. Delirium, and the agitation and confusion that can accompany the disorder, is very frustrating for families and caregivers. Nursing management and family interventions are particularly important in the management of this complex disorder.

scholarly journals Rhabdomyosarcomas in Young Pigs in a Swine Breeding Farm: A Morphologic and Immunohistochemical Study

1993 ◽  
Vol 30 (3) ◽  
pp. 271-279 ◽  
Author(s):  
J. H. Vos ◽  
G. H. A. Borst ◽  
J. Martin de las Mulas ◽  
F. C. S. Ramaekers ◽  
F. N. van Mil ◽  
...  
Keyword(s):  
Immunohistochemical Study ◽  
Myogenic Differentiation ◽  
Electron Microscopic Examination ◽  
Clinical History ◽  
Electron Microscopic ◽  
Dense Bodies ◽  
Young Pigs ◽  
Cytoplasmic Filaments ◽  
Short Period ◽  
High Incidence

Within a 6-month-period, solitary or multiple tumors were observed in 25 young pigs in their first weeks of life in a swine breeding farm. The herd comprised approximately 100 animals, and affected pigs were observed in several litters. The number of affected littermates varied from one to three. Five animals, all from different litters and with a total of 11 tumors, were studied. Histologically the tumors were classified as undifferentiated sarcomas. Electron microscopic examination of the tumors ( n = 3) revealed myogenic differentiation, characterized by the presence of numerous cytoplasmic filaments with longitudinal densities and cytoplasmic dense bodies. Immunohistochemically, all 11 tumors were labeled by vimentin and desmin antibodies. Two tumors from which frozen material was available were additionally labeled by a titin antibody but did not show immunoreactivity with antibodies directed against myosin and α-sarcomeric actin. The tumors were finally diagnosed as undifferentiated rhabdomyosarcomas. The high incidence of these tumors within a short period of time in multiple young animals in different litters indicates a common causative event. The clinical history suggests a genetic cause.

scholarly journals EMERGENCY LAPAROTOMIES UNDER SPINAL ANESTHESIA: A RETROSPECTIVE, FACILITY BASED OBSERVATIONAL STUDY, IN KABUL, AFGHANISTAN

2021 ◽  
Vol 9 (06) ◽  
pp. 751-756
Author(s):  
Wais Farda ◽  
◽  
Ahmad Bashir Nawazish ◽  
Keyword(s):  
Length Of Stay ◽  
Observational Study ◽  
General Anesthesia ◽  
Spinal Anesthesia ◽  
Average Length ◽  
Emergency Laparotomy ◽  
Complication Rates ◽  
Abdominal Incision ◽  
Significant Difference ◽  
The Mean

Background: Laparotomy is most commonly performed under general anesthesia, but spinal anesthesia (SA) is considered an alternative to in the context of limited resources. The safety and efficacy of using SA as substitute for general anesthesia(GA) has not been explored in Afghanistan. Methodology: We conductedan observational study in the general surgery department of Isteqlal hospital in Kabul, Afghanistan on 196 adult patients undergoing emergency laparotomy under spinal anesthesia betweenApril 2018-April 2020. Results: The mean age of patients was 41.5 years (SD=19.4), the ratio of males to females was 1.9:1 and almost half (44.4%) had comorbidities. 21% were classified as ASA grade III and IV with a similar pattern among males and females. A total of 11 (5.6%) cases were converted to GA. Conversion pattern to GA was similar amongmales and females(P=0.71), ASA grade (P=0.432) and age group (P=0.642). The mean length of stay after operation was 6.5 days (SD=4.1). 32 (16.3%) patients suffered SA complications with no significant difference in terms of sex (P=0.134). Hypotension and headache accounted for 97% of complications. Complication rates were similar in terms of intervertebral level (P=0.349), type of abdominal incision (P>0.1) and average length of stay (P=0.156). 18 patients (9.2%) died due to MOF, sepsis, respiratory failure, thromboembolism and cardiogenic shock. Conclusion: Spinal anesthesia is considered a safe and effective anesthesia for emergency laparotomies, even for those with comorbidities. Based on our findings we would recommend spinal anesthesia as an alternative to general anesthesiain emergency laparotomy in Afghanistan.

scholarly journals SP3.1.3 Use of a Care Bundle to reduce Surgical Site Infection after Emergency Laparotomy

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
C Swain ◽  
J Rogers ◽  
D Gane ◽  
M Quinn ◽  
J Hopkins ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Surgical Site Infection ◽  
Care Bundle ◽  
Emergency Laparotomy ◽  
Site Infection ◽  
Skin Preparation ◽  
Elective Colorectal Surgery ◽  
Changing Practice ◽  
Patient Reported ◽  
Surgical Teams

Abstract Aim Surgical Site Infection (SSI) is common after abdominal surgery. A care bundle was introduced to sustainably reduce SSI after elective colorectal surgery. This study aimed to implement an expanded care bundle after emergency laparotomy. Methods Quality improvement methodology was used. SSI was measured by direct assessment of the wound in patients in hospital at 30 days. For discharged patients, the PHE SSI surveillance questionnaire was used to measure patient-reported SSI 30 days post-operatively. The care bundle included: 2% chlorhexidine skin preparation; dual ring wound protectors; triclosan-coated sutures for wound closure; second dose of antibiotics >4 hours, betadine to the wound and glove change before closure. Bundle compliance was measured and fed back to surgical teams. Results Baseline SSI was 13.5% (178 patients) which reduced to 8.5% (118 patients) following bundle introduction. Response rate was 60%. Compliance with antibacterial sutures was measured for patients whose wounds were closed; 10% received negative pressure dressings. Mortality within 30 days was 9%. Length of stay reduced from mean 22.6 to 12.45, median 13.5 to 9 days. Conclusion The care bundle reduced SSI after emergency laparotomy. Measuring SSI is more difficult after emergency surgery due to higher death rate, longer length of stay and use of laparostomy. Other challenges include difficulty using wound protectors for some procedures e.g. adhesiolysis and changing practice from use of skin clips.

scholarly journals TP9.2.16Peri-operative Delirium in the Emergency Laparotomy Population

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Michael McCusker ◽  
Jennifer Edwards ◽  
Margaret Clark
Keyword(s):  
Length Of Stay ◽  
Cognitive Dysfunction ◽  
Risk Score ◽  
Assessment Tool ◽  
Treatment Guidelines ◽  
Emergency Laparotomy ◽  
Care Pathways ◽  
Calendar Period ◽  
Site Survey ◽  
Baseline Characteristics

Abstract Aims To determine the incidence of peri-operative delirium in our emergency laparotomy population. Methods Utilising our local prospectively maintained Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) database all cases over a two-month calendar period were identified. Case notes were reviewed retrospectively for all patients. The 4 A's Test (4AT) assessment tool was used to screen for the presence of delirium (a score ≥4 = delirium), performed throughout the peri-operative period. For all patients baseline characteristics were recorded including NELA risk score, 30 day survival, length of stay (LOS), ASA score, age, sex and presence of pre-morbid cognitive dysfunction. Results Thirty-two patients were identified through the ELLSA database. Incidence of peri-operative delirium as determined by 4AT was 10/32 patients (31.25%). The thirty day mortality was 4/32 (12.5%). Peri-operative delirium was identified in all non-survivors. NELA risk score for those with delirium 14% / 21% (median / mean) versus 2.5% / 2.3% (median / mean) without (p 0.0015). The LOS for those with delirium 26 / 24.6 days (median / mean) versus 11 / 13.6 (median / mean) without (p 0.0194). Conclusions Delirium is a common peri-operative event. In our population it is associated with a higher NELA score. The presence of delirium is associated with poorer outcomes, with an increased mortality and LOS. This single site survey indicates that there is a need to develop care pathways that identify those at risk of delirium and implement treatment guidelines. Our survey suggests that the NELA score could be used as a triage tool for the risk of delirium.

scholarly journals Does declared surgeon specialist interest influence the outcome of emergency laparotomy?

2020 ◽  
Vol 102 (6) ◽  
pp. 437-441
Author(s):  
S Hallam ◽  
M Bickley ◽  
L Phelan ◽  
M Dilworth ◽  
DM Bowley
Keyword(s):  
Length Of Stay ◽  
General Surgery ◽  
Special Interest ◽  
Operative Procedure ◽  
Emergency Laparotomy ◽  
Emergency General Surgery ◽  
Call Structure ◽  
Increased Risk ◽  
The Uk ◽  
National Emergency

Introduction In the UK, general surgeons must demonstrate competency in emergency general surgery before obtaining a certificate of completion of training. Subsequently, many consultants develop focused elective specialist interests which may not mirror the breadth of procedures encountered during emergency practice. Recent National Emergency Laparotomy Audit analysis found that declared surgeon special interest impacted emergency laparotomy outcomes, which has implications for emergency general surgery service configuration. We sought to establish whether local declared surgeon special interest impacts emergency laparotomy outcomes. Methods Adult patients having emergency laparotomy were identified from our prospective National Emergency Laparotomy Audit database from May 2016 to May 2019 and categorised as colorectal or oesophagogastric according to operative procedure. Outcomes included 30-day mortality, return to theatre and length of stay. Binomial logistic regression was used to identify any association between declared consultant specialist interest and outcomes. Results Of 600 laparotomies, 358 (58.6%) were classifiable as specialist procedures: 287 (80%) colorectal and 71 (20%) oesophagogastric. Discordance between declared specialty and operation undertaken occurred in 25% of procedures. For colorectal emergency laparotomy, there was an increased risk of 30-day mortality when performed by a non-colorectal consultant (unadjusted odds ratio 2.34; 95% confidence interval 1.10–5.00; p = 0.003); however, when adjusted for confounders within multivariate analysis declared surgeon specialty had no impact on mortality, return to theatre or length of stay. Conclusion Surgeon-declared specialty does not impact emergency laparotomy outcomes in this cohort of undifferentiated emergency laparotomies. This may reflect the on-call structure at Birmingham Heartlands Hospital, where a colorectal and oesophagogastric consultant are paired on call and provide cross-cover when needed.

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