Indirect effects of the covid-19 pandemic on childhood infection in England: population based observational study

ObjectiveTo assess the impact of the covid-19 pandemic on hospital admission rates and mortality outcomes for childhood respiratory infections, severe invasive infections, and vaccine preventable disease in England.DesignPopulation based observational study of 19 common childhood respiratory, severe invasive, and vaccine preventable infections, comparing hospital admission rates and mortality outcomes before and after the onset of the pandemic in England.SettingHospital admission data from every NHS hospital in England from 1 March 2017 to 30 June 2021 with record linkage to national mortality data.PopulationChildren aged 0-14 years admitted to an NHS hospital with a selected childhood infection from 1 March 2017 to 30 June 2021.Main outcome measuresFor each infection, numbers of hospital admissions every month from 1 March 2017 to 30 June 2021, percentage changes in the number of hospital admissions before and after 1 March 2020, and adjusted odds ratios to compare 60 day case fatality outcomes before and after 1 March 2020.ResultsAfter 1 March 2020, substantial and sustained reductions in hospital admissions were found for all but one of the 19 infective conditions studied. Among the respiratory infections, the greatest percentage reductions were for influenza (mean annual number admitted between 1 March 2017 and 29 February 2020 was 5379 and number of children admitted from 1 March 2020 to 28 February 2021 was 304, 94% reduction, 95% confidence interval 89% to 97%), and bronchiolitis (from 51 655 to 9423, 82% reduction, 95% confidence interval 79% to 84%). Among the severe invasive infections, the greatest reduction was for meningitis (50% reduction, 47% to 52%). For the vaccine preventable infections, reductions ranged from 53% (32% to 68%) for mumps to 90% (80% to 95%) for measles. Reductions were seen across all demographic subgroups and in children with underlying comorbidities. Corresponding decreases were also found for the absolute numbers of 60 day case fatalities, although the proportion of children admitted for pneumonia who died within 60 days increased (age-sex adjusted odds ratio 1.71, 95% confidence interval 1.43 to 2.05). More recent data indicate that some respiratory infections increased to higher levels than usual after May 2021.ConclusionsDuring the covid-19 pandemic, a range of behavioural changes (adoption of non-pharmacological interventions) and societal strategies (school closures, lockdowns, and restricted travel) were used to reduce transmission of SARS-CoV-2, which also reduced admissions for common and severe childhood infections. Continued monitoring of these infections is required as social restrictions evolve.

Outcomes of day case shoulder replacement surgery in a stand-alone day care unit in the United Kingdom

Background: This review aims to compare the outcomes for day case shoulder replacement with in-patient shoulder replacement surgery in a district general hospital. Methods: Seventy-three patients had 82 shoulder arthroplasty procedures. Forty-six procedures were undertaken in a dedicated stand-alone day-case unit and 36 were undertaken as in-patient cases. Patient were followed up at 6 weeks, 6 months and annually. Results: There was no significant difference between the outcomes of shoulder arthroplasty procedures performed in the day case or in-patient settings making this a safe option for surgical care in a unit with an appropriate care pathway. Six complications in total were observed, three in each group. Operation time was statistically shorter for day cases by 25.1 min (95% CI - 36.5 to −13.7; d = −0.95, 95% CI −1.42 to 0.48). Estimated marginal means (EMM) revealed lower post-surgery oxford pain scores in day cases (EMM = 3.25, 95% CI 2.35, 4.16) compared with inpatients (EMM = 4.65, 95% CI 3.64 to 5.67). Constant shoulder scores were higher in day cases versus inpatients. Conclusion: Day case shoulder replacement is safe with comparable outcomes to routine inpatient care for patients up to ASA 3 classification with high satisfaction and excellent functional outcomes.

Mortality following elective and emergency colectomy in patients with cirrhosis: a population-based cohort study from England

Background Patients with cirrhosis undergoing colectomy have a higher risk of postoperative mortality, but contemporary estimates are lacking and data on associated risk and longer term outcomes are limited. This study aimed to quantify the risk of mortality following colectomy by urgency of surgery and stage of cirrhosis. Data sources. Linked primary and secondary-care electronic healthcare data from England were used to identify all patients undergoing colectomy from January 2001 to December 2017. These patients were classified by the absence or presence of cirrhosis and severity. Case fatality rates at 90 days and 1 year were calculated, and cox regression was used to estimate the hazard ratio of postoperative mortality controlling for age, gender and co-morbidity. Results Of the total, 36,380 patients undergoing colectomy, 248 (0.7%) had liver cirrhosis, and 70% of those had compensated cirrhosis. Following elective colectomy, 90-day case fatality was 4% in those without cirrhosis, 7% in compensated cirrhosis and 10% in decompensated cirrhosis. Following emergency colectomy, 90-day case fatality was higher; it was 16% in those without cirrhosis, 35% in compensated cirrhosis and 41% in decompensated cirrhosis. This corresponded to an adjusted 2.57 fold (95% CI 1.75–3.76) and 3.43 fold (95% CI 2.02–5.83) increased mortality risk in those with compensated and decompensated cirrhosis, respectively. This higher case fatality in patients with cirrhosis persisted at 1 year. Conclusion Patients with cirrhosis undergoing emergency colectomy have a higher mortality risk than those undergoing elective colectomy both at 90 days and 1 year. The greatest mortality risk at 90 days was in those with decompensation undergoing emergency surgery.

A nurse-led day-case gastroenterology service in the emergency department

The incidence of liver disease has been steadily increasing, and patients with severe, symptomatic ascites need paracentesis (drainage) of the ascitic fluid for management. The authors and colleagues have previously developed a nurse-led and nurse-managed day-case gastroenterology service that provides paracentesis and other treatments, such as blood transfusion and specialist biologic infusions to patients with inflammatory bowel disease (IBD) and other gastroenterological conditions. This article describes the development of a similar novel nurse-led day-case service within the emergency department (ED) to provide a front-door urgent service for patients attending ED and needing paracentesis/infusions. It also reflects on the journey to developing this service, as well as the challenges faced during to the COVID-19 pandemic.

O-EGS02 Effective use of afternoon Day Case Theatre Lists for Emergency Laparoscopic Cholecystectomy on Emergency Surgery Ambulatory Care (ESAC) Pathway

Background Gallstone disease is a common entity and affects up to 10-15% of the European population. The majority of these cases are asymptomatic but approximately 20% will develop complications such as severe biliary colic, cholecystitis, choledocholithiasis and pancreatitis. Early cholecystectomy in patients suffering from symptomatic gallstones can improve post-operative outcomes, avoid re-attendance and reduce overall length of hospital stay. We describe how two afternoon day case theatre lists were successfully utilised to prevent surgical admissions by enabling laparoscopic cholecystectomy on an urgent basis. Methods A sustainable pathway for symptomatic gallstones was introduced to Emergency Surgery Ambulatory Care (ESAC). Patients presenting with acute symptoms, well enough for ambulatory care, were referred to ESAC for diagnosis and management. Patients fit for surgery underwent pre-operative assessment before being operated on one of two weekly afternoon lists. A standardised, evidence-based approach was used for all laparoscopic cholecystectomies to ensure homogeneity of technique and patient care. This included pre-incision local anaesthetic, low flow and pressures intra-operatively, adequate analgesia to-take-home, and follow-up telephone consultation at 48hrs. Prospective data collection began in 2019 looking at hospital admission rate and 30-day re-presentation. Results Analysis was performed on data collected from September 2019 to July 2021. 151 patients had laparoscopic cholecystectomies, 107 were female and 44 male. Age range was 18-83 (median age 49) and median time to operation was 3 days. Overall, the spectrum of gallstone disease was 81 biliary colic, 44 cholecystitis, 20 pancreatitis and 6 choledocholithiasis. 18 patients were admitted post-operatively with length of stay ranging 1-6 days (median 1.5 days). 17 patients re-presented within 30 days, mainly for abdominal or pleuritic chest pain, although one patient required ERCP for CBD stones and another had pancreatitis. Conclusions Emergency surgery for symptomatic gallstone disease can be performed successfully on a day case basis. At our centre, the rate of post-operative admission was 12% and 30-day re-presentation was 11%. Standardisation of referrals, assessment and operative technique can achieve excellent outcomes with low rates of hospital admission and post-operative complications.

Day Case GreenLight Laser Photoselective Vaporisation of the Prostate (GL-PVP)

Background and ObjectiveIn recent years, GreenLight laser photoselective vaporisation of the prostate (GL-PVP) has emerged as the primary ablative surgical treatment option for symptomatic bladder outlet obstruction (BOO) secondary to benign prostatic enlargement (BPE). Unlike the reference procedure, monopolar-transurethral resection of the prostate (M-TURP), GL-PVP can be performed as a day case. As waiting list pressures continue to burden health boards across the UK, exacerbated by the COVID-19 pandemic, enhanced access to day case surgery to optimise patient flow is now of paramount importance. We evaluated the safety and feasibility of day case GL-PVP at our high-volume UK centre and identified predictors of a postoperative overnight stay. Material and MethodsWe performed a retrospective observational cohort study of all patients who underwent primary GL-PVP at a single institution between October 2016 and June 2021. All procedures were performed utilising the 180W GreenLight XPS™ laser therapy system. Various clinical, operative and functional data were collated, and outcomes were compared between patients who underwent day case surgery and those admitted overnight postoperatively. ResultsIn all, 538 patients underwent GL-PVP during the study period. Median patient age was 72 (interquartile range (IQR) 66–77), and median prostate volume was 62.5cc (IQR 45–90). Five hundred nineteen patients (96.5%) were discharged within 23 hours of admission, and 366 patients (68.0%) were managed as a true day case. Operative and functional outcomes were comparable between patients managed as a day case and those admitted overnight. There was higher patient-reported satisfaction and a lower rate of early hospital readmission in the day-case group. On univariate logistic regression analysis, patients aged ≥80 years (Odds Ratio 2.64 [95% Confidence Interval 1.65– 4.24], p = < 0.001), those with American Society of Anaesthesiologists (ASA) physical status classification score ≥3 (OR 1.92 [95% CI 1.33–2.78], p = < 0.001), those with prostate volume ≥80cc (OR 1.62 [95% CI 1.00–2.61], p = 0.05) and those in whom the operation time ≥60 minutes (OR 1.66 [95% CI 1.10–2.52], p = 0.02) were more likely to be admitted overnight following GL-PVP. On multivariate logistic regression analysis, age ≥80 (OR 2.64 [95% CI 1.47–4.73], p = 0.001) and ASA score ≥3 (OR 2.03 [95% CI 1.28–3.22], p = 0.003) remained predictive variables of an overnight stay. ConclusionFrom our observations of a large cohort of patients over a study period of almost five years, day case GL-PVP is a feasible concept and does not appear to compromise perioperative outcomes. With appropriate service redesign and optimisation of postoperative patient pathways, day case GL-PVP can be established in other centres and may have a role in alleviating waiting list pressures.