O-EGS09 Effect of introducing an ambulatory care service on management of patients requiring acute cholecystectomy

Abstract Background Biliary pathology is a large tranche of the emergency surgical take, taking up many bed days, with many patients not receiving definitive management on their primary admission. An Emergency Surgical Ambulatory Care (ESAC) service was established at our hospital in 2019, aiming to provide a streamlined platform for diagnosis and surgical management of patients. Most notably this included patients with symptomatic gallstones which could be managed on a semi-urgent basis without hospital admission. We aim to analyse the efficiency of this novel service in hopes of identifying room for improvement so that we may enhance our patient outcomes. Methods Two time periods were retrospectively assessed; September-December 2018 (pre- ESAC) and September-December 2019 (six months after ESAC started). Patients with Cholelithiasis (ICD-K80) and Cholecystitis (ICD-K81) were identified, and those with either an incidental diagnosis of gallstones without symptoms, with gallstone pancreatitis, severe inflammation (empyema, gangrene, perforation), requiring ERCP or if they were unfit for surgery were excluded. Data was collected on number of admissions, length of stay and rate of cholecystectomy. Patients were divided into 2018 SAU, 2019 SAU and 2019 ESAC to compare the difference in their outcomes. Data are presented as median (range). Results Some 57 patients presented acutely in 2018 compared to 82 in 2019. The median wait to operation of 43.5 days in 2018 was significantly reduced to 7 days in 2019. Conclusions The introduction of an ESAC service in 2019 has allowed a reduction in number of admissions, total length of stay of patients and significantly reduced waiting time for surgery. Use of ESAC has shown to be more efficient in terms of hospital bed occupation and indirectly, utilization of resources. The high surgical success rate also ensures fewer patients re-presenting with the same pathology to the acute take and hence contributes to reducing strain on the on-call team. Further work is being done to reduce the number of patients presenting through the SAU pathway, and preferentially attending through ESAC.

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SP3.2.10 Establishing an Emergency Surgical Ambulatory Care (ESAC) pathway for acute laparoscopic cholecystectomies: a single centre experience from a District General Hospital

British Journal of Surgery ◽

10.1093/bjs/znab361.076 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Neil Donald ◽

Lavanya Varatharajan ◽

Kumaran Ratnasingham ◽

Shashi Irukulla

Keyword(s):

Laparoscopic Cholecystectomy ◽

Length Of Stay ◽

Ambulatory Care ◽

Operating Time ◽

District General Hospital ◽

Gallstone Pancreatitis ◽

Early Laparoscopic Cholecystectomy ◽

Patient Demographics ◽

Day Range ◽

Cost Efficiencies

Abstract Aims Early laparoscopic cholecystectomy is the gold standard for acute cholecystitis and gallstone pancreatitis. In order to deliver this service, a local Emergency Surgical Ambulatory Care (ESAC) pathway with a dedicated ESAC theatre list was established. The aim of this audit was to determine whether ESAC was associated with (1) improved length of stay and (2) cost efficiencies. Methods Consecutive patients who underwent an emergency laparoscopic cholecystectomy between October 2018 to October 2019 were identified. Data related to patient demographics, operating time, complications length of stay (LOS), reason for inpatient stay and re-admissions were collected. A dedicated ESAC service was introduced in July 2020. Outcomes were re-audited (July – December 2020). Results Prior to the introduction of ESAC, 142 patients (42% male, mean age 51 years (range 14 -82 years)) underwent an acute cholecystectomy, of which 13% were discharged on the same day. Median pre-operative LOS was 2 days (range 0-12 days) and median post-operative LOS was 1 day (range 1-16 days). Following the introduction of ESAC, 78 patients (32% male, mean age 49 years (range 22 – 89 years)) underwent an acute cholecystectomy, of which 76% were discharged on the same day and 90% within 1 day. Median pre-operative LOS was 0 days (range 0 to 7 days) and median post-operative LOS was 0 days (range 0-16 days). Conclusions Our results show that the introduction of a dedicated ESAC pathway improved both pre- and post-operative LOS. This subsequently saves approximately £80,000 per annum in hospital bed days.

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EP.WE.726A snapshot audit of cholecystectomy for gallstone pancreatitis during the first wave of COVID-19

British Journal of Surgery ◽

10.1093/bjs/znab308.087 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Bryony David ◽

Sony Aiynattu ◽

Katie Jones ◽

Antonio Gallucci

Keyword(s):

Length Of Stay ◽

Average Length ◽

Surgical Care ◽

Index Admission ◽

Gallstone Pancreatitis ◽

Data Set ◽

Time To Surgery ◽

Number Of Patients ◽

And Gender ◽

Acute Gallstone Pancreatitis

Abstract Aims COVID-19 has caused difficulties in providing efficient surgical care. We aimed to audit cholecystectomy provision for gallstone pancreatitis from January 2019 to June 2020. We audited time from admission with gallstone pancreatitis to cholecystectomy in pre-COVID and COVID cohorts in order to assess the effect of the first wave of the pandemic on service provision. Methods Patients with confirmed gallstone pancreatitis plus their age and gender were included using information software Cerner. We analysed length of stay, time to surgery and number of patients planned for surgery. We also looked at readmissions whilst awaiting surgery. Patients with previous cholecystectomies or deemed not fit for surgery were excluded. Results 68 patients were included; 42 admitted from Jan 2019 to Feb 2020 (non-COVID group) and 26 from March 2020 to June 2020 (COVID 19 group). Average length of stay was 11.8 days for non-COVID group and 8.8 days for COVID group. Average time to surgery for non-COVID group was 47.4 days. 25 patients underwent surgery. Average time to surgery was 56.7 days and 9 patients received surgery, in the COVID group. In this group, 3 patients had index admission surgery compared to 15 in the non-COVID group. Conclusions Albeit small, our data set shows a longer wait to surgery in the COVID group with fewer operations performed at index admission, compared to the non-COVID group. Future surgical services will require careful planning to ensure that urgent cholecystectomies continue to be performed in acute gallstone pancreatitis.

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EP.WE.613A multi-centre review of the management of acute appendicitis during the COVID-19 pandemic

British Journal of Surgery ◽

10.1093/bjs/znab308.075 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Jessica Ruth Lockhart ◽

Scarlett O'Brien ◽

Lara Armstrong ◽

Aidan Armstrong ◽

Damian McKay

Keyword(s):

Acute Appendicitis ◽

Conservative Management ◽

Gold Standard ◽

Standard Treatment ◽

Ct Scans ◽

Control Group ◽

Diagnostic Uncertainty ◽

Number Of Patients ◽

The Difference ◽

Definitive Management

Abstract Aim Acute appendicitis is a common surgical presentation and is historically a clinical diagnosis; gold-standard treatment is appendicectomy. Due to anticipated increased demand on in-patient beds during the COVID-19 pandemic there was increased emphasis on conservative management of acute appendicitis. Our aim is to review these changes and determine the representation rate following conservative management. Methods Patients with acute appendicitis were identified from daily referral lists across two trusts. Data was collected using electronic care records. A control group (106 patients) was identified from 3 months preceding the pandemic. Results In the pandemic group, 213 patients had acute appendicitis; 47% were managed conservatively, compared to 8% of the control group. Overall, during the pandemic 44% of patients had a CT-confirmed diagnosis (compared to 48% of control group); the two trusts’ results varied showing 75% and 30% (compared to 46% and 51% respectively in the control group). Of those treated conservatively only 3% represented to hospital and required admission. Conclusion Significantly more patients were treated conservatively during the COVID-19 pandemic. The larger number of patients managed as acute appendicitis in the pandemic group may represent over-diagnosis due to the decision to conservatively manage these patients and account for diagnostic uncertainty. Increased access to early diagnostic CT scans facilitated early decisions regarding definitive management. Variation in access to radiology both during and before the pandemic may account for the difference in use of CT scans. Low rates of readmission to hospital following conservative management of acute appendicitis have been observed to date.

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EP.TH.916Managing Gallstone Pancreatitis: Are We Doing Enough?

British Journal of Surgery ◽

10.1093/bjs/znab309.092 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Salim Malik ◽

Thomas Evans ◽

Shafquat Zaman ◽

Misra Budhoo

Keyword(s):

Acute Pancreatitis ◽

Length Of Stay ◽

Hospital Discharge ◽

Gallstone Disease ◽

Index Admission ◽

Gallstone Pancreatitis ◽

National Guidelines ◽

Acute Gallstone Pancreatitis ◽

Mean Time ◽

Definitive Management

Abstract Background Acute pancreatitis carries significant morbidity and has an estimated annual incidence of 30-50/100,000 in the U.K. 50% of these cases are related to gallstone disease. NICE/BSG guidelines recommend definitive management of gallstone pancreatitis during the index admission or within 14 days of hospital discharge. We audited our compliance against these national guidelines. Methods Retrospective data was collected for patients admitted with acute gallstone pancreatitis over a 12-month period. Patient demographics, admission details, length of stay, previous/future admissions, timing of cholecystectomy and ERCP were recorded. Results 47 patients were included (mean age: 50.7 years) with a mean length of stay of 6.2 days. Only 6% had a cholecystectomy during the index admission or within 14 days of hospital discharge. 12 (26%) patients had an ERCP performed with a mean time of 45 days. The mean time to surgery after initial discharge was 97 days. Conclusion There is poor compliance with national guidelines in the management of gallstone related pancreatitis in our cohort of patients. Definitive management reduces readmissions, resulting in financial savings and improved patient care. This audit demonstrates the need to develop a robust ‘hot gallbladder’ pathway to improve the management of patients with acute pancreatitis secondary to gallstones.

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Planning for End of Life

American Journal of Hospice and Palliative Medicine® ◽

10.1177/10499091211014166 ◽

2021 ◽

pp. 104990912110141

Author(s):

Natasha Ansari ◽

Eric Johnson ◽

Jennifer A. Sinnott ◽

Sikandar Ansari

Keyword(s):

End Of Life ◽

Treatment Options ◽

Stage Iv ◽

P Value ◽

Life Planning ◽

Number Of Patients ◽

End Of Life Planning ◽

The Difference ◽

Alternative Medications ◽

Patient’S Perception

Background: Oncology provider discussions of treatment options, outcomes of treatment, and end of life planning are essential to care for patients with advanced malignancies. Studies have shown that despite this, many patients do not have adequate care planning, including end of life planning. It is thought that the accessibility of information outside of clinical encounters and individual factors and/or beliefs may influence the patient’s perception of disease. Aims: The objective of this study was to evaluate if patient understanding of treatment goals matched the provider and if there were areas of discrepancy. If a discrepancy was found, the survey inquired further into more specific aspects. Methods: A questionnaire-based survey was performed at a cancer hospital outpatient clinic. 100 consecutive and consenting patients who had stage IV non-curable lung, gastrointestinal (GI), or other cancer were included in the study. Patients must have had at least 2 visits with their oncologist. Results: 40 patients reported their disease might be curable and 60 reported their disease was not curable. Patients who reported their disease was not curable were more likely to be 65 years or older (P-value: 0.055). They were more likely to report that their doctor discussed the possibility of their cancer getting worse (78.3% VS 55%; P-value 0.024), that their doctor discussed end of life plans (58.3% VS 30%; P- value: 0.01), and that they had appointed a health care decision-maker (86.7% VS 62.5%; P-value: 0.01). 65% of patients who thought their disease might be curable reported that their doctor said it might be curable, compared with only 6.7% of patients who thought their disease was not curable (p < 0.001). Or, equivalently, 35% of patients who thought their disease might be curable reported that their doctor’s opinion was that it was not curable, compared with 93% of patients who thought their disease was not curable (p < 0.001). Patients who had lung cancer were more likely to believe their cancer was not curable than patients with gastrointestinal or other cancer, though the difference was not statistically significant (p = 0.165). Patients who said their disease might be curable selected as possible reasons that a miracle (50%) or alternative medicine (66.7%) would get rid of the cancer, or said their family wanted them to believe the cancer would go away (16.7%) or that another doctor said it would (4.2%). Patients who said their disease might be curable said they did so due to alternative medications, another doctor, or their family. Restricting to the 70 patients who reported their doctors telling them their disease was not curable, 20% of them still said that they personally felt their disease might be curable. Patients below 65 years of age were more likely to disagree with the doctor in this case (P-value: 0.047). Conclusion: This survey of patients diagnosed with stage IV cancer shows that a significant number of patients had misunderstandings of the treatment and curability of their disease. Findings suggest that a notable proportion kept these beliefs even after being told by treating physicians that their disease is not curable.

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39 Managing Burn Wounds with Silvadene

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.043 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S29-S30

Author(s):

Tomer Lagziel ◽

Louis J Born ◽

Luis H Quiroga ◽

Eliana Duraes ◽

Pragna N Shetty ◽

...

Keyword(s):

Length Of Stay ◽

Wound Infection ◽

Standard Of Care ◽

Infection Rates ◽

Average Amount ◽

Once Daily ◽

Preliminary Results ◽

The Difference ◽

Dressing Change ◽

Hospital Acquired

Abstract Introduction Topical delivery of antibacterial agents is typically incorporated and is an essential component of burn wound therapy. The goal is to prevent infection and promote the healing process. Poorly treated wounds can result in scarring or severely in sepsis and multi-organ dysfunction. Topical SSD cream has been the gold-standard for initial local care in partial thickness or full thickness burns. Due to immediate burst release of the drug into the exposed areas, application is relatively frequent (usually twice daily). However, it remains unknown whether twice-daily SSD dressings are superior to once-daily. Methods We maintained a twice-daily dressing change standard of care until 01/01/2019. Patients admitted after that date had their dressing changed once-daily. Our goal is to review outcomes for 75 patients before the change-of-practice and 75 patients after. The main outcomes recorded are wound infection rates, hospital-acquire complications (non-wound related), pain scores, daily narcotic requirements, average amount of SSD used, and length-of-stay. Results Preliminary results of the 75 pre-change-of-practice and 75 post-change-of-practice patients showed slightly better outcomes in the post-change group. Wound-infection rates were the same for both groups (pre=5.33%, post=5.33%), average daily pain-levels for the pre-change group were slightly higher but the difference was negligible and not statistically significant (pre=5.76, post=5.69). The pre-change group had a higher average daily narcotic dosage (pre=6.81mg, post=6.38mg), hospital-acquired complication rates were higher pre-change (pre=10.67%, post=6.67%), and length-of-stay was longer in the pre-change group (pre=10.81, post=9.25). The average amount of SSD jars used per patient was higher as well (pre=6.30, post=2.85). Statistical analysis of the distribution of burn type, age, and burn depth showed no discrepancy and a generalized decreased length-of-stay with once-daily SSD dressing change. Conclusions Preliminary results show that once-daily dressing changes of SSD in burn wounds have no negative impact on wound outcomes. However, it is associated with a decreased length-of-stay, decreased pain levels, and less hospital-acquired complications. A decreased length-of-stay means reduced medical expenses for the patient and the hospital. In addition, less hospital-acquired complications result in better patient recovery. Since the difference in wound outcomes is negligible and statistically insignificant, changing the standard-of-care to once-daily could prove beneficial.

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Home Mechanical Ventilation: A Patient’s Perspective Survey Study

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18084048 ◽

2021 ◽

Vol 18 (8) ◽

pp. 4048

Author(s):

Magdalena Kwiatosz-Muc ◽

Bożena Kopacz

Keyword(s):

Health Care ◽

Mechanical Ventilation ◽

Alternative Methods ◽

Survey Study ◽

Home Mechanical Ventilation ◽

Patient’S Satisfaction ◽

Satisfaction Index ◽

Number Of Patients ◽

The Difference

Background: An increasing number of patients included in home mechanical ventilation (HMV) care has been under observation for many years. The study aimed to assess the patients opinion concerning the expected and perceived quality of care in an HMV system and a patient’s satisfaction with care. Methods: In 2017, patients treated with HMV were surveyed in Poland with the modified SERVQUAL questionnaire. Results: One hundred correctly completed surveys were analyzed. Patient Satisfaction Index was high. In every examined area, the expectations were statistically significant larger than the perception of the services. The biggest gap was in the tangibility dimension and the smallest gap was in the empathy dimension. Perceived respect and understanding for a patient’s needs are close to the expectations. Conclusions: The level of satisfaction with health care among patients treated with HMV in majority of investigated components is high. Moreover, the difference between perceived and expected quality of health care in the HMV system was relatively small in the opinion of the patients themselves. Further investigations with alternative methods are needed.

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An Environmental Scan of Ambulatory Care Quality Indicators for Patients With Advanced Kidney Disease Currently Used in Canada

Canadian Journal of Kidney Health and Disease ◽

10.1177/2054358121991096 ◽

2021 ◽

Vol 8 ◽

pp. 205435812199109

Author(s):

Jay Hingwala ◽

Amber O. Molnar ◽

Priyanka Mysore ◽

Samuel A. Silver

Keyword(s):

Kidney Disease ◽

Ambulatory Care ◽

Quality Indicators ◽

Health Care Quality ◽

Healthcare Research ◽

Care Quality ◽

Institute Of Medicine ◽

Environmental Scan ◽

Number Of Patients ◽

Ambulatory Patients

Background: Quality indicators can be used to identify gaps in care and drive frontline improvement activities. These efforts are important to prevent adverse events in the increasing number of ambulatory patients with advanced kidney disease in Canada, but it is unclear what indicators exist and the components of health care quality they measure. Objective: We sought to identify, categorize, and evaluate quality indicators currently in use across Canada for ambulatory patients with advanced kidney disease. Design: Environmental scan of quality indicators currently being collected by various organizations. Setting: We assembled a 16-member group from across Canada with expertise in nephrology and quality improvement. Patients: Our scan included indicators relevant to patients with chronic kidney disease in ambulatory care clinics. Measurements: We categorized the identified quality indicators using the Institute of Medicine and Donabedian frameworks. Methods: A 4-member panel used a modified Delphi process to evaluate the indicators found during the environmental scan using the American College of Physicians/Agency for Healthcare Research and Quality criteria. The ratings were then shared with the full panel for further comments and approval. Results: The environmental scan found 28 quality indicators across 7 provinces, with 8 (29%) rated as “necessary” to distinguish high-quality from poor-quality care. Of these 8 indicators, 3 were measured by more than 1 province (% of patients on a statin, number of patients receiving a preemptive transplant, and estimated glomerular filtration rate at dialysis start); no indicator was used by more than 2 provinces. None of the indicators rated as necessary measured timely or equitable care, nor did we identify any measures that assessed the setting in which care occurs (ie, structure measures). Limitations: Our list cannot be considered as an exhaustive list of available quality indicators at hand in Canada. Our work focused on quality indicators for nephrology providers and programs, and not indicators that can be applied across primary and specialty providers. We also focused on indicator constructs and not the detailed definitions or their application. Last, our panel does not represent the views of other important stakeholders. Conclusions: Our environmental scan provides a snapshot of the scope of quality indicators for ambulatory patients with advanced kidney disease in Canada. This catalog should inform indicator selection and the development of new indicators based on the identified gaps, as well as motivate increased pan-Canadian collaboration on quality measurement and improvement. Trial registration: Not applicable as this article is not a systematic review, nor does it report results of a health intervention on human participants.

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P17 An audit of Trakcare discharge times for Laparoscopic Cholecystectomy

BJS Open ◽

10.1093/bjsopen/zrab032.016 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

Author(s):

Jacob Rapier ◽

Steven Hornby ◽

Jacob Rapier

Keyword(s):

Laparoscopic Cholecystectomy ◽

Length Of Stay ◽

Initial Data ◽

Best Practice ◽

Average Length ◽

Accurate Data ◽

Day Case ◽

Average Length Of Stay ◽

Number Of Patients ◽

Elective Laparoscopic Cholecystectomy

Abstract Introduction Nationally 61,220 Laparoscopic Cholecystectomies are carried out annually. Those carried out as day-cases reduce providers’ costs and increase income through the best practice tariff. The system in our trust to record discharges is ‘Trakcare’. The aim of this audit was to accurately measure the discharge times of patients undergoing elective Laparoscopic Cholecystectomies, to try and reduce the number of patients recorded as having an overnight stay by accurate data collection. Methods Initial data was collected for all elective Laparoscopic Cholecystectomy discharge times on Trakcare, over a 1 month period. This data was then re-audited prospectively both from Trakcare and discharges reported by nurses/patients. A comparison was then made of Trakcare against reported discharge times. Results Initially 54 operations were recorded, with 30 completed as day cases (55.6%). The re-audited data (on Trakcare) recorded 47 operations, with 15 completed as day cases (37.91%). Of these discharges we were able to capture 26 (55.32%) manually, and 11 were completed as day cases (42.31%). Measuring these 26 with the same operations on Trakcare we were unable to show a difference in the number of cases completed as a day case (11 vs 11), with only a 33 minute decrease in the average length of stay. Conclusion Trakcare is a reliable tool for measuring the date of discharge for patients. The recommendations in are: scheduling surgery for a time pre-13:00 shows a higher proportion of patients discharged the same day, and continue to use Trakcare to record discharge times.

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Identifying priorities for primary care investment in Ireland through a population-based analysis of avoidable hospital admissions for ambulatory care sensitive conditions (ACSC)

BMJ Open ◽

10.1136/bmjopen-2018-028744 ◽

2019 ◽

Vol 9 (11) ◽

pp. e028744 ◽

Cited By ~ 1

Author(s):

Geraldine McDarby ◽

Breda Smyth

Keyword(s):

Primary Care ◽

Ambulatory Care ◽

Integrated Care ◽

Hospital Admissions ◽

Acute Hospital ◽

Ambulatory Care Sensitive Conditions ◽

Hospital System ◽

Bed Days ◽

Ambulatory Care Sensitive ◽

Sensitive Conditions

BackgroundIn 2016, the Irish acute hospital system operated well above internationally recommended occupancy targets. Investment in primary care can prevent hospital admissions of ambulatory care sensitive conditions (ACSCs).ObjectiveTo measure the impact of ACSCs on acute hospital capacity in the Irish public system and identify specific care areas for enhanced primary care provision.DesignNational Hospital In-patient Enquiry System data were used to calculate 2011–2016 standardised bed day rates for selected ACSC conditions. A prioritisation exercise was undertaken to identify the most significant contributors to bed days within our hospital system. Poisson regression was used to determine change over time using incidence rate ratios (IRR).ResultsIn 2016 ACSCs accounted for almost 20% of acute public hospital beds (n=871 328 bed days) with adults over 65 representing 69.1% (n=602 392) of these. Vaccine preventable conditions represented 39.1% of ACSCs. Influenza and pneumonia were responsible for 99.8% of these, increasing by 8.2% (IRR: 1.02; 95% CI 1.02 to 1.03) from 2011 to 2016. Pyelonephritis represented 47.6% of acute ACSC bed days, increasing by 46.5% (IRR: 1.07; 95% CI 1.06 to 1.08) over the 5 years examined.ConclusionsPrioritisation for targeted investment in integrated care programmes is enabled through analysis of ACSC’s in terms of acute hospital bed days. This analysis demonstrates that primary care investment in integrated care programmes for respiratory ACSC’s from prevention to rehabilitation at scale could assist with bed capacity in acute hospitals in Ireland. In adults 65 years and over, including chronic obstructive pulmonary disease patients, the current analysis supports targeting community based pulmonary rehabilitation including pneumococcal and influenza vaccination programmes in order to reduce the burden of infection and hospitalisations. Further exploration of pyelonephritis is necessary in order to ascertain patient profile and appropriateness of admissions.

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