TP10.1.5The reorganisation of Emergency General Surgery services during the COVID-19 pandemic in the UK: Outcomes of delayed presentation, mortality and BAME patients

Abstract Background The COVID-19 pandemic is a global public health emergency. The reconfiguration of local healthcare systems to accommodate the increase in Critical Care capacity has put strain on ‘non-COVID’ specialities. This study characterises the utilisation of Emergency General Surgery (EGS) services at a busy UK university teaching hospital during the COVID-19 lockdown period to evaluate outcomes and to identify patient groups with worse outcomes. Method This retrospective study compares EGS admissions during the UK’s lockdown period (23rd March-28th May 2020) to the same period in 2019. Patient demographics were recorded together with details of their hospital stay and treatment outcomes. Results A total of 645 patients were included, comprising 223 in the COVID-19 and 422 in the non-COVID-19 periods. There was no difference in age, sex, co-morbidity or socioeconomical status. A lower proportion of Black, Asian and Minority Ethnic (BAME) patients were admitted during the COVID-19 period (20.6% vs 35.4%, p < 0.05). The duration of symptoms prior to presentation were longer, and admission Early Warning Scores and serum inflammatory markers were higher. More patients present with acute kidney injury (9.9% vs 4.7%, p = 0.012). There was no difference in perioperative outcomes or 30-day mortality, but more patients were readmitted following conservative management (10.6% vs 4.7%, p = 0.023). Conclusion We show that the UK reorganisation of EGS services has been successful in terms of outcomes and access to services despite a more unwell population. There was a lower proportion of BAME admissions suggesting additional barriers to access to healthcare under pandemic lockdown conditions.

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658 Managing the Acute Surgical Patient – How has COVID-19 Changed Our Approach?

British Journal of Surgery ◽

10.1093/bjs/znab259.474 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

J Wall ◽

R Maguire ◽

T Plotkin ◽

M Kowal ◽

A Peckham-Cooper

Keyword(s):

Similar Proportion ◽

Surgical Patient ◽

Delayed Presentation ◽

Emergency General Surgery ◽

Cross Sectional ◽

Tertiary Centre ◽

Chi Squared ◽

Cross Sectional Imaging ◽

Sectional Imaging ◽

The Uk

Abstract Aim COVID-19 has changed how surgical admissions are triaged and treated. This retrospective cohort study aims to detail the effects of a national lockdown on emergency general surgical referrals at a tertiary centre. Method A retrospective search identified all emergency general surgery referrals prior to and during the UK national lockdown. Pre (10-23 Feb 2020;PLG) and intra-lockdown (30 Mar-12 Apr 2020;ILG) groups were compared using descriptive statistics and significance was quantified with Chi-squared. Results 600 patients were included of which 426 (71%) presented in the PLG. The PLG had proportionally fewer ED referrals (40.8%vs.51.1%, p = 0.02) and less cross-sectional imaging performed (31.5%vs.40.8%, p = 0.03). There was a significant reduction in non-specific abdominal pain (NSAP) during lockdown (25.12%vs.14.94%, p = 0.007). GP referrals (48.8%vs.46.6%, p = 0.61), admission (46.2%vs.44.8%, p = 0.09) and operative intervention (21.4% vs.17.24%, p = 0.25) showed no disparity. Conclusions Predictably, the advent of lockdown resulted in a reduction in hospital attendance and surgical referrals. Our data showed a similar proportion of referred patients admitted pre- and intra-lockdown despite a reduction in absolute terms. This may be due to a trend towards later presentation coupled with a focus on conservative management and prevention of admission. The decrease in NSAP raises questions that require further exploration. Cross-sectional imaging was used more freely as an adjunct in the ILG suggesting increasing acuity and delayed presentation or may result from a tendency towards image-guided discharge. Admissions have since trended towards pre-lockdown levels, but it is yet to be seen if a reduction in elective operating will lead to an increase in emergency admissions.

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

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2020.0098 ◽

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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EP.WE.238Implications of COVID-19 on Laparoscopic General Surgery: a single site experience

British Journal of Surgery ◽

10.1093/bjs/znab308.032 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Eloise Lawrence ◽

Panos Stathakis ◽

Paul Goldsmith ◽

Stella Smith ◽

Christian Macutkiewicz ◽

...

Keyword(s):

Laparoscopic Surgery ◽

General Surgery ◽

Conservative Management ◽

Service Provision ◽

Complication Rates ◽

Emergency General Surgery ◽

Admission Rates ◽

Unknown Risk ◽

The Uk ◽

The Impact

Abstract Introduction and Aims The COVID-19 pandemic has had an unprecedented impact on service provision in Emergency General Surgery. Due to the unknown risk of COVID-19 transmission, the use of laparoscopic surgery was cautioned against in favour of open surgery or conservative management. This study looks at the impact of service reconfiguration on rates of laparoscopic surgery. Methods The management and outcomes were audited of all patients admitted to our unit during the UK COVID-19 lockdown period and compared against the same period last year. Results In total, 645 patients (223 COVID-19 period, 422 non-COVID) were included. Less surgery was performed during the pandemic (32.3% vs 39.3%), with only 2 cases of laparoscopic surgery (0.9% vs 16.1%). Despite a change to conservative management, we report no differences in complication rates or length of stay and 30-day mortality (excluding deaths from COVID-19 pneumonitis). Re-admission rates were higher following conservative management (10.6% vs 4.7%). Conclusion There is a significant reduction in surgery (particularly laparoscopic surgery) during the COVID-19 pandemic. There are no differences in outcomes, but we show higher re-admission rates for patients treated conservatively. Together with emerging evidence on the safety of laparoscopic surgery, these findings help inform service re-configuration for future pandemic responses.

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Outcomes of COVID-19 patients that needed emergency general surgery: predictors of mortality and postoperative complications

10.21203/rs.3.rs-676027/v1 ◽

2021 ◽

Author(s):

Katya Bozada-Gutiérrez ◽

Mario Trejo-Avila ◽

Carlos Valenzuela-Salazar ◽

Jesús Herrera-Esqu ◽

Mucio Moreno-Portillo

Keyword(s):

Postoperative Complications ◽

Length Of Stay ◽

General Surgery ◽

Perioperative Outcomes ◽

Emergency General Surgery ◽

Entire Cohort ◽

Prolonged Length ◽

Symptomatic Disease ◽

Predictors Of Mortality ◽

Prediction Of Mortality

Abstract Purpose There is limited data about the perioperative outcomes of COVID−19 patients that needed emergency general surgery. The aims of the present study were to describe the perioperative outcomes of COVID−19 patients that underwent emergency general surgery and to determine possible predictors of mortality and postoperative complications. Methods A prospective study of positive COVID−19 patients that needed an emergency general surgery procedure at our center was performed. Results From March 2020 to February 2021, 44 patients were included. We found that patients with SARS-CoV−2 symptomatic disease have increased postoperative complications, higher ICU admissions, prolonged length of stay, and decreased 90-day survival as compared with asymptomatic COVID−19 patients. The 90-day survival probability of the entire cohort was 70.1% (60.3–79.9) and was significantly lower in patients with COVID−19 symptoms 63.4% (50.5–76.2). We found the following cut-off values for the prediction of mortality: ferritin ≥ 438.5 ng/mL (AUC = 0.908), CRP value ≥ 12.5 mg/dL (AUC = 0.715), leukocyte ≥ 13.8 x103/µL (AUC = 0.706), and albumin ≤ 2.78 g/dL (AUC = 704,). Also, a cut-off value of CRP of ≥ 12.5 mg/dL yielded an accuracy of 82.9% for the prediction of postoperative complications (p < 0.001). Conclusion Patients with symptomatic COVID−19 that needed emergency surgery have increased postoperative complications, higher ICU admissions, prolonged length of stay, and decreased 90-day survival as compared with asymptomatic COVID−19 patients. Preoperative ferritin, CRP, leukocytes, and albumin could be used as predictors of mortality.

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Association of Intellectual Disability with Delayed Presentation and Worse Outcomes in Emergency General Surgery

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2021.07.600 ◽

2021 ◽

Vol 233 (5) ◽

pp. S290

Author(s):

Allyse N. Zondlak ◽

Esther J. Oh ◽

Pooja Neiman ◽

Zhaohui Fan ◽

Kathryn K. Taylor ◽

...

Keyword(s):

Intellectual Disability ◽

General Surgery ◽

Delayed Presentation ◽

Emergency General Surgery

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P-EGS09 The Introduction of an Ambulatory Surgical Pathway

British Journal of Surgery ◽

10.1093/bjs/znab430.069 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

Joshua Wall ◽

Katie Boag ◽

Mikolaj Kowal ◽

Tobias Plotkin ◽

Rachel Maguire ◽

...

Keyword(s):

Primary Care ◽

General Surgery ◽

Similar Proportion ◽

Control Group ◽

Emergency General Surgery ◽

Telephone Advice ◽

Assessment Unit ◽

The Uk ◽

Surgical Pathway ◽

Hospital Acquired

Abstract Background Since the publication of the Emergency General Surgery Commissioning Guide by ASGBI in 2014, there has been a drive to develop ambulatory pathways for acute surgical patients, saving inpatient stays and reducing the risk of hospital-acquired infections. Many units, like ours, had a large workload increased by seeing next day returns as well as acute presentations. In October 2020 an Institute of Emergency General Surgery was formed who developed an ambulatory pathway to ameliorate some of these issues and provide a point of contact for primary care referrals, for one the busiest emergency general surgical takes in the UK. Methods A retrospective analysis was undertaken to identify all acute referrals to general surgery over a 14-day period in February 2019 prior to (Pre-ASC) and 2021 after (Post-ASC) the introduction of an Ambulatory Surgical Clinic (ASC). All patient episodes were reviewed, and descriptive statistics on overall attendance to the surgical assessment unit (SAU), admissions to inpatient wards and referrals to ASC were analysed. Patients presenting to the acute urology take were used as a control to compare the number patients attending the surgical assessment unit both before and during the COVID-19 pandemic. Results 830 patients presented over the 28-day study period (426 pre-ACS vs 404 post-ACS; 5% reduction), totalling 992 patient encounters including planned returns (525 vs 467; 11% reduction). After the introduction of the ASC total attendance to SAU was reduced by 42% (525 vs 306); next day return attendances were reduced by 87% (99 vs 13) and attendances from primary care were reduced by 68% (208 vs 67). The proportion of patients admitted was similar (46% vs 50%). 146 patients attended the ASC, and 15 patients received telephone advice alone. The control group saw attendance increase by 25% (178 vs 223). Conclusions The results clearly show that the introduction of the ASC has decreased attendance to SAU, freeing clinicians to dedicate more time to those acutely unwell. The similar proportion of admissions after the introduction of the ASC suggests that the ambulatory pathway correctly identifies those who are well enough to be managed as outpatients. The increased attendance in the control group suggests that the data were not the results of a decrease in referrals due to COVID-19. The results shared here should encourage other large units to consider developing ambulatory pathways.

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Anticoagulation in Emergency General Surgery

Case Medical Research ◽

10.31525/ct1-nct04216394 ◽

2020 ◽

Author(s):

Keyword(s):

General Surgery ◽

Emergency General Surgery

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An exploration of migrant women’s perceptions of public health messages to reduce stillbirth in the UK: a qualitative study

BMC Pregnancy and Childbirth ◽

10.1186/s12884-021-03879-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Tomasina Stacey ◽

Melanie Haith-Cooper ◽

Nisa Almas ◽

Charlotte Kenyon

Keyword(s):

Public Health ◽

Perinatal Mortality ◽

Health Professionals ◽

Health Messages ◽

Migrant Women ◽

Global Public Health ◽

Wide Range ◽

Public Health Messages ◽

Associated Risk Factors ◽

The Uk

Abstract Background Stillbirth is a global public health priority. Within the United Kingdom, perinatal mortality disproportionately impacts Black, Asian and minority ethnic women, and in particular migrant women. Although the explanation for this remains unclear, it is thought to be multidimensional. Improving perinatal mortality is reliant upon raising awareness of stillbirth and its associated risk factors, as well as improving maternity services. The aim of this study was to explore migrant women’s awareness of health messages to reduce stillbirth risk, and how key public health messages can be made more accessible. Method Two semi-structured focus groups and 13 one to one interviews were completed with a purposive sample of 30 migrant women from 18 countries and across 4 NHS Trusts. Results Participants provided an account of their general awareness of stillbirth and recollection of the advice they had been given to reduce the risk of stillbirth both before and during pregnancy. They also suggested approaches to how key messages might be more effectively communicated to migrant women. Conclusions Our study highlights the complexity of discussing stillbirth during pregnancy. The women in this study were found to receive a wide range of advice from family and friends as well as health professionals about how to keep their baby safe in pregnancy, they recommended the development of a range of resources to provide clear and consistent messages. Health professionals, in particular midwives who have developed a trusting relationship with the women will be key to ensuring that public health messages relating to stillbirth reduction are accessible to culturally and linguistically diverse communities.

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