EP.WE.20At a glance: the impact of COVID-19 on Emergency General Surgery

Abstract Aim This study investigated the impact of COVID-19 on emergency general surgery practice, in a district general hospital in the United Kingdom, particularly on referrals, diagnosis, investigations, management pathways, outcomes, patient behaviour and consultant practice. Methods Retrospective data collection from two cohorts: 112 patients admitted over one week in pre-COVID period and 90 patients admitted over one week during the COVID period. We used patient questionnaire and a consultant questionnaire to collect data on patient behaviour and consultant practice. Results Almost four times and seven times increase in performed X-rays (CXRs)and CT-thorax-abdomen-pelvis (TAPs) respectively. The COVID period saw 6.5% increase in conservative and 6.2% reduction in surgical management, and about 50% decline in length of stay (LoS) in conservatively managed patients. 71% of patients’ decisions to attend hospital were not affected and 78.6% of consultant surgeons preferred to manage patients conservatively during the COVID period. Conclusion Overall, there were delayed patients’ presentations to hospital at almost twice, increase in paediatric referrals, a surge in performed scans, and a reduction in hospital stay in patients who were managed conservatively. Patient behaviour to attend hospital was not heavily influenced by COVID, but consultant practice certainly changed towards more conservative choices. Future studies should explore the impact on paediatric referrals and long-term effects on surgical training. This study's manuscript has been accepted for publication in the Surgical Practice Journal.

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892 Emergency General Surgical Practice at a District General Hospital during COVID-19 Pandemic: Implementing Royal College of Surgeons Guidance

British Journal of Surgery ◽

10.1093/bjs/znab134.502 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

K Hashmi ◽

S Khalid ◽

K Raja ◽

A Zaka ◽

J Easterbrook

Keyword(s):

Informed Consent ◽

Royal College ◽

Mortality Risk ◽

General Surgery ◽

Surgical Care ◽

District General Hospital ◽

Emergency General Surgery ◽

Surgical Practice ◽

Full Compliance ◽

Type Of Surgery

Abstract Introduction COVID-19 pandemic had a significant impact on surgical practice across NHS. RCS released guidance on altering surgical practise during the pandemic to deliver safe surgical care in March, 2020. We present an audit conducted at a DGH comparing practice of emergency general surgery (EGS) with RCS guidance at the peak of COVID-19 pandemic. Method Consecutive patients undergoing EGS from 1st April to 15th May,2020. Data of demographics, ASA grade, comorbidities, type of surgery, hospital stay, informed COVID-19 pneumonia consent, complications and 30-day mortality were collected. Pre- and post-operative COVID-19 status was determined. Results Forty-four (n = 44) patients, mean age 47.5 and IQR (26-69). Male (55.8%) and females (44.2%). Preoperative COVID19 status was confirmed in around 79.1% patients. All (100%) patients who underwent CT imaging preoperatively had CT chest performed. Informed consent for COVID19 pneumonia was taken in 4.7% patients. 30-day mortality risk was 7% and complications risk was 4.7%. RR of 30-day mortality in preoperative COVID19 status positive patients was RR = 0.92 (CI 0.85-1.01) and for complications was RR = 0.95 (CI 0.88-1.02). Conclusions RCS guidance on managing and altering practice in EGS during COVID-19 pandemic is reliable, implementable, and measurable in a DGH setting. Simple improvements in consent process can achieve full compliance with RCS guidelines.

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The Obesity Paradox in Emergency General Surgery Patients

The American Surgeon ◽

10.1177/0003134820968524 ◽

2021 ◽

pp. 000313482096852

Author(s):

Sean R. Maloney ◽

Caroline E. Reinke ◽

Abdelrahman A. Nimeri ◽

Sullivan A. Ayuso ◽

A. Britton Christmas ◽

...

Keyword(s):

General Surgery ◽

Multivariable Analysis ◽

Operative Management ◽

Chronic Obstructive ◽

High Morbidity ◽

Emergency General Surgery ◽

Common Procedure ◽

Increased Risk ◽

Social Security Death Index ◽

The Impact

Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.

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EMERGENCY SURGERY DURING COVID 19 AT K.A.P.V GOVERNMENT MEDICAL COLLEGE AND MGMGH , TRICHY

10.36106/ijar/8200303 ◽

2021 ◽

pp. 6-9

Author(s):

Sumathi Ravikumar ◽

Yeganathan Rajappan ◽

Durairajan Vaithiyanathan ◽

Catherine Sindhuja

Keyword(s):

Surgical Intervention ◽

District General Hospital ◽

Favourable Outcome ◽

Emergency General Surgery ◽

Emergency Admissions ◽

Medical College ◽

Prolonged Duration ◽

Current Impact ◽

Emergency Surgical Intervention ◽

The Impact

COVID 19 pandemic was declared by WHO as public health emergency on January 30,2020. Health system was reorganised with the aim to cope with the new disease and maintain essential health service. Many patients suffered from ARDS which lead to the modication of clinical and surgical activity. Current impact of COVID 19 outbreak on emergency surgical practice is still not developed. Varied presentation, diagnostic uncertainity, lack of guidelines present challenges to surgeons. AIM: The aim of our study was to evaluate the impact of the COVID-19 pandemic on emergency general surgery admissions and operations in our institution METHODS: We conducted a retrospective study in K.A.P.V.G.M.C. and M.G.M.G.H., Trichy from march 2020 to December 2020. All general surgical emergency admissions to KAPVGMC and MGMGH, district general hospital were included from march to December 2020.The details of diagnosis and subsequent management were retrieved from records. CONCLUSION: It was observed thatclinical decisions were made based on urgency of each case while simultaneously evaluating their COVID 19 status. The number of surgicalcases during COVID 19 period were signicantly reduced. Recognising asymptomatic carriers and need of emergency surgical intervention were the challenges faced by the surgeons. Effective communication between microbiologist, radiologist, anaesthetist and surgeon was necessary to attain a favourable outcome. .Inspite of challenges faced 80% had postoperative uneventful period other than prolonged duration of stay and were discharged and followed up. Covid 19 pneumonia and ARDS attributed to majority of death among the 20 % of deceased , other than septicemia

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Creation and implementation of a novel clinical workflow based on the AAST uniform anatomic severity grading system for emergency general surgery conditions

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000552 ◽

2020 ◽

Vol 5 (1) ◽

pp. e000552 ◽

Cited By ~ 1

Author(s):

Kovi E Bessoff ◽

Jeff Choi ◽

Sylvia Bereknyei Merrell ◽

Aussama Khalaf Nassar ◽

David Spain ◽

...

Keyword(s):

Patient Care ◽

General Surgery ◽

Qualitative Interviews ◽

Grading System ◽

Clinical Workflow ◽

Emergency General Surgery ◽

Level Of Evidence ◽

Severity Scores ◽

Severity Grading ◽

The Impact

ObjectiveEmergency general surgery (EGS) conditions encompass a variety of diseases treated by acute care surgeons. The heterogeneity of these diseases limits infrastructure to facilitate EGS-specific quality improvement (QI) and research. A uniform anatomic severity grading system for EGS conditions was recently developed to fill this need. We integrated this system into our clinical workflow and examined its impact on research, surgical training, communication, and patient care.MethodsThe grading system was integrated into our clinical workflow in a phased fashion through formal education and a written handbook. A documentation template was also deployed in our electronic medical record to prospectively assign severity scores at the time of patient evaluation. Mixed methods including a quantitative survey and qualitative interviews of trainees and attending surgeons were used to evaluate the impact of the new workflow and to identify obstacles to its adoption.ResultsWe identified 2291 patients presenting with EGS conditions during our study period. The most common diagnoses were small bowel obstruction (n=470, 20.5%), acute cholecystitis (n=384, 16.8%), and appendicitis (n=370, 16.1%). A total of 21 qualitative interviews were conducted. Twenty interviewees (95.2%) had a positive impression of the clinical workflow, citing enhanced patient care and research opportunities. Fifteen interviewees (75.0%) reported the severity grading system was a useful framework for clinical management, with five participants (25.0%) indicating the system was useful to facilitate clinical communication. Participants identified solutions to overcome barriers to adoption of the clinical workflow.ConclusionsThe uniform anatomic severity grading system can be readily integrated into a clinical workflow to facilitate prospective data collection for QI and research. The system is perceived as valuable by users. Educational initiatives that focus on increasing familiarity with the system and its benefits will likely improve adoption of the classification system and the clinical workflow that uses it.Level of evidenceLevel III.

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COVID-19: Adapting to change, general surgery at a district general hospital in the United Kingdom

Journal of Perioperative Practice ◽

10.1177/1750458920950558 ◽

2019 ◽

Vol 30 (10) ◽

pp. 301-308

Author(s):

Sonia Ike ◽

Chijioke Ikechi ◽

Jaideep Rait ◽

Ankur Shah

Keyword(s):

United Kingdom ◽

General Hospital ◽

General Surgery ◽

Major Change ◽

Holistic Approach ◽

District General Hospital ◽

Viral Spread ◽

The United Kingdom ◽

Staff Wellbeing ◽

Surgery Department

The Coronavirus pandemic has caused major change across the world and in the National Health Service. In order to cope and help limit contagion, numerous institutions recognised the need to adjust clinical practice quickly yet safely. In this paper, we aim to describe the changes implemented in a general surgery department at a district general hospital in the United Kingdom. Across the surgical specialties, frameworks, protocols and guidelines have been established locally and nationally. The aerosol generating procedures involved in general surgery required us to alter our daily activities. Modifications to patient management were necessary to try and reduce viral spread. Staff wellbeing was heavily promoted in order to help maintain the frontline workforce. A holistic approach was required.

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Emergency general surgery in the United Kingdom

Journal of Trauma and Acute Care Surgery ◽

10.1097/ta.0000000000002010 ◽

2018 ◽

Vol 85 (3) ◽

pp. 500-506 ◽

Cited By ~ 7

Author(s):

George Ramsay ◽

Jared M. Wohlgemut ◽

Jan O. Jansen

Keyword(s):

United Kingdom ◽

General Surgery ◽

Emergency General Surgery ◽

The United Kingdom

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Does the COVID-19 Pandemic Affect Morbidity and Mortality Rates of Emergency General Surgery? A Retrospective Study from a Single-Center Tertiary Greek Hospital

Medicina ◽

10.3390/medicina57111185 ◽

2021 ◽

Vol 57 (11) ◽

pp. 1185

Author(s):

Eleni Karlafti ◽

Emmanouil S. Benioudakis ◽

Daniel Paramythiotis ◽

Konstantinos Sapalidis ◽

Georgia Kaiafa ◽

...

Keyword(s):

General Surgery ◽

Control Period ◽

Mortality Rates ◽

Common Type ◽

First Year ◽

Emergency General Surgery ◽

Time Periods ◽

Surgery Department ◽

The Impact ◽

Type Of Surgery

Background and Objectives: The outbreak of the COVID-19 pandemic had a major impact on all aspects of health care. Few up-to-date studies have actually assessed the impact of COVID-19 on emergency surgeries. The aim of this study was to provide an overview of the impact of the pandemic relating to the emergency surgery performed, as well as morbidity and mortality rates during the first year of the pandemic (March 2020–February 2021) and during the control period. In this period, the first propaedeutic surgery department and the third surgery department of the University General Hospital of Thessaloniki “AHEPA” in Greece provided continuous emergency general surgery services. Material and Methods: The study is in a retrospective cohort and included patients who were admitted to the Emergency Department and underwent emergency general surgery during the control period (n = 456), March 2019–February 2020 and during the first year of the pandemic (n = 223), March 2020–February 2021. Gender, age, type of surgical operation (morbidity), ICU need, the patient’s outcome, and days of hospitalization were compared. Results: A total of 679 emergency surgeries were included. Statistically significant differences emerged between the two time periods in the total number of emergency surgeries performed (p < 0.001). The most common type of surgery in the control period was associated with soft tissue infection while, during the pandemic period, the most common type of surgery was associated with the hepatobiliary system. In addition, the mortality rates nearly doubled during the pandemic period (2.2% vs. 4%). Finally, the mean age of our sample was 50.6 ± 17.5 and the majority of the participants in both time periods were males. Conclusions: The COVID-19 pandemic changed significantly the total number of emergency general surgeries performed. Mortality rates doubled and morbidity rates were affected between the control and pandemic periods. Finally, age, gender, length of hospitalization, intensive care unit hospitalization, and laparoscopy use in patients undergoing emergency surgery during the pandemic were stable.

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SP3.2.4 Creating sub-specialty emergency surgical care and changing consultant working patterns improves consultant morale and stress levels

British Journal of Surgery ◽

10.1093/bjs/znab361.071 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Edward Hardy ◽

Thomas Smart ◽

Jacob Hatt ◽

Jon Lund

Keyword(s):

Length Of Stay ◽

Perceived Stress ◽

General Surgery ◽

Surgical Care ◽

Emergency General Surgery ◽

Quality Of Patient Care ◽

Stress Levels ◽

General Surgeons ◽

The Impact

Abstract Aims General surgery consultants have some of the highest rates of burnout. Ever increasing emergency general surgery (EGS) admissions playing a major role in this. A move to create split sub-speciality cover consisting of upper GI/HPB (UGI) and colorectal (CR) consultants has been suggested to improve EGS outcomes. We assessed the impact changing on-call working patterns had on perceived consultant stress levels, manageability of their workload and patient length of stay (LOS). Methods Consultant on call patterns changed from an individual consultant covering four consecutive weekdays to two consultants (one UGI/HPB, one CR) sharing four consecutive weekdays. Consultants were surveyed to assess the impact of this change on the manageability of their workload and their perceived stress levels. Admission numbers and LOS were also analysed for all EGS admissions over a 6-month period either side of the rota change. Results 89% of consultants who responded chose to work the new on call format. 78% felt it had improved the manageability of their workload, decreased perceived stress levels and improved quality of patient care. There was no change in the number of EGS admissions (862 vs 866) or EGS patient length over the time periods studied (Pre: 0D: 8%, 1 – 2D 38%, 3 – 4D 19%, >4D 34%. vs Post: 0D 8%, 1 – 2D 40%, 3 – 4D 17%, > 4D 35%). Conclusions A move to shorter and sub-specialty on call duties reduced stress and improved manageability for consultant general surgeons without adverse impact on patient’s length of stay.

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SP4.1.4 Stay at home, protect the NHS, Save lives? The impact of the COVID-19 pandemic on acute surgical services

British Journal of Surgery ◽

10.1093/bjs/znab361.084 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Oliver Brewster ◽

Dale Thompson ◽

Emma Sewart ◽

Sarah Richards

Keyword(s):

Abdominal Pain ◽

General Surgery ◽

District General Hospital ◽

Surgical Patients ◽

Emergency Admissions ◽

Emergency Operations ◽

Surgical Services ◽

The Mean ◽

The Impact ◽

Second Wave

Abstract Aims Several centres described a ‘lockdown effect’: a reduction in emergency surgical admissions during national lockdown (23/03/20-01/06/20). The extent and reproducibility of this is unclear. We evaluated the impact of the COVID-19 pandemic on emergency general surgical activity in a district general hospital. Methods We conducted a retrospective analysis of patients admitted under general surgery and urology between 01/01/2017-31/12/2020 using coding data. Unpaired t-tests were used to compare the total monthly admissions, admissions by diagnosis and monthly operations performed between the ‘first wave’ (April-May 2020) and ‘average’ (all months 2017-2019), and between the ‘second wave’ (November-December 2020) and average. Results Overall emergency admissions in 2020 were reduced compared to the mean 2017-2019 (4498 vs 5037). Monthly admissions were significantly reduced in the first wave compared to 2017-2019 (mean monthly admissions=284.5 vs 419.8; p < 0.001) with the greatest reduction in patients with non-specific abdominal pain (mean=58 vs 109; p = <0.001). A significant reduction in monthly admissions with pancreatitis (mean=8.0 vs 14.6; p = 0.010) and diverticulitis (mean=10.5 vs 18.8; p = 0.028) were also observed. This effect was less apparent during the second wave (mean total admissions=384.5 vs 419.8; p = 0.249). Monthly emergency operations were reduced in both the first wave compared to average (68 vs 101.9; p = 0.007) and the second wave (74.5 vs 101.9; p = 0.025). Conclusions We found strong evidence of a ‘lockdown effect’ in our centre during the first wave. The cause is unclear and likely to be multifactorial. Further research is needed to evaluate whether surgical patients came to harm as a result.

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Emergency surgery (DRAFT)

10.1093/med/9780198749813.003.0007 ◽

2018 ◽

Author(s):

Jonathan Wild ◽

Emma Nofal ◽

Imeshi Wijetunga ◽

Antonia Durham Hall

Keyword(s):

General Surgery ◽

Hospital Admissions ◽

Surgical Intervention ◽

Elective Surgery ◽

Trauma Surgery ◽

Emergency Operation ◽

Emergency General Surgery ◽

Symptom Palliation ◽

The Impact ◽

Theatre List

Emergency general surgery comprises patients with surgical problems requiring surgical intervention or post-operative surgical patients who require further surgical intervention or symptom palliation at any time of the day or night. Beyond the cases discussed below, this will include also emergency presentations from all of the sub-specialty chapters covered so far. Over 600,000 emergency hospital admissions are made to general surgery. Of these patients, they comprise the sickest patient cohort relative to the majority of elective patients, which results from sepsis, shock, or organ dysfunction from the underlying causative pathology, as well as the impact of any pre-existant comorbid states. This often has a significant impact on patient outcome, with high rates of morbidity and mortality relative to elective surgery. With this in mind, a lot of work has been channelled into improving outcomes for these patients. Furthermore, emergency and trauma surgery is beginning to establish itself as a subspecialty in itself. This chapter starts by making applied discussion of the assessment and initial investigation of acute abdominal pain, a complaint that comprises half of the annual 600,000 emergency general surgical admissions. It covers the pertinent features of diagnosis, investigation, and management of a range of common or serious emergency surgical and trauma cases that will be encountered on the acute surgical take. Kidney transplantation is not in itself an emergency operation when you consider the degree of pre-operative preparation of recipient donors, but is included in this chapter as it is commonly encountered by junior trainees on the emergency theatre list when donors are found at short notice.

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