Reducing Health Care Burden of Emergency General Surgery with a 24-Hour Dedicated Emergency General Surgery Service

Background Emergency general surgery (EGS) diagnoses account for 11% of surgical admissions and 50% of surgical mortality. In this population, 7 specific operations are associated with 80.3% of deaths, 78.9% of complications, and 80.2% of hospital costs. In 2016, our institution established a comprehensive in-house EGS service. Herein, we hypothesize that formation of a dedicated EGS service is associated with a significant reduction in morbidity for patients undergoing the most common EGS procedures. Methods All patients undergoing one of the most common EGS procedures within 2 days of admission were identified from 1/1/2013 to 5/9/2019 via a retrospective chart review. Patients were cohorted as pre- and post-EGS implementation. The primary outcome measure was the overall complication rate. Secondary endpoints included mortality, individual complication rate, time to operation, overnight operation, and length of stay. Finally, both cohorts were benchmarked to national outcomes. Results 718 patients met inclusion criteria (pre-EGS = 409 and post-EGS = 309). Overall complication rate decreased significantly (19.8% vs 13.9%, P = .0387) and overnight operations increased significantly in the post-EGS group (7.8%-16.5%, P = .0003). Pre-EGS complications were higher than national data in all but 1 procedure group, whereas post-EGS complications rates were lower in all but 2 categories. Discussion Implementation of a dedicated EGS service line was associated with a significant decrease in complication rate among the most complication-prone EGS procedures. Number of operations within 24 hours did not increase significantly; however, overnight operations did increase. Our results indicate that establishing a service-specific EGS line is reasonable and beneficial.

P-EGS14 From Gallstone Disease to Cholecystectomy: An audit looking at the waiting times for cholecystectomy in a small District General Hospital

Background Gallstone-related disease accounts for a third of emergency general surgery admissions and referrals. The average waiting time for acute gallstone presentations to laparoscopic cholecystectomy is about 7 days in England. This audit aims to identify emergency admissions and compare local management to the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) guidelines standards with a focus on waiting times for laparoscopic cholecystectomy (LC). Where AUGIS standards were not met, number of re-admissions and complications were identified. A cost analysis was also completed looking at the overall costs of delayed treatment. Methods We identified all patients admitted as an emergency between September 2019 and September 2020 with gallstone-related pathology. Patients not referred to the surgical team, with negative Ultrasound Scans (USS) or known HPB malignancy were excluded. The patients were divided into a pre- COVID -19 and during COVID-19 category (respectively before and after March 2020), to identify whether the cancellation to non- urgent elective surgery (due to COVID-19) had caused further delays or complications. Each patient’s management was compared to AUGIS guidelines depending on their diagnosis at presentation (biliary colic, cholecystitis, cholangitis, gallstone-related pancreatitis), focusing on the timing between presentation and LC. Results A total of 99 patients were identified. Of the patients presenting with biliary colic (n = 9 pre-COVID, n = 5 during COVID), none underwent LC within 72 hours from presentation as recommended by AUGIS. Of the patients presenting with cholecystitis (n = 20 pre-COVID and n = 16 during COVID), none had LC within the recommended 72 hours. 5 patients in each COVID group had LC, with a significantly longer waiting time compared to the pre-COVID group. Re-admissions and complications were similar for the cholecystitis patients in both COVID groups. In the gallstone-related pancreatitis group, only 1 patient underwent LC within the recommended 2 weeks. Conclusions This audit showed that locally we are failing to meet AUGIS guidelines for LC within 72 hrs, 2 weeks or 6 weeks both pre and during COVID. This has caused re-admissions of patients with cholecystitis, pancreatitis and perforated gallbladders. Factors that cause delay are limited access to USS, limited staff and theatre availability. To improve outcomes, it is necessary to implement a hot gallbladder service with dedicated theatre slots. A change in the overall perception of LC is also needed: this is should be considered an emergency operation as its delay has a significant negative impact on patients’ outcomes.

P-O14 The predictive role of pre-operative liver function tests in outcomes following emergency appendicectomy

Background Acute appendicitis remains one of the most common diagnoses in emergency general surgery, with recent evidence from the COMMA trial confirming that appendicectomy is the cornerstone of definitive management in most patients. With a wide range of severity and of patient physiology, complications are a burden to patients and the health service. We hypothesised that liver function tests have predictive value for complications following emergency appendicectomy. Methods A multicentre retrospective observational study was carried out across 4 hospitals (2 teaching centres and 2 district general hospitals) for adult patients who underwent emergency appendectomy between August 2018 and November 2020. Patients were identified through pathology records and data was extracted from electronic case records for patient demographics, pre-operative routine laboratory results, operative details, and clinical outcomes. Peak perioperative liver function parameters were analysed using unpaired two-way T-tests, Pearson’s correlation coefficient, ANOVA and multivariate regression to determine their relationship with conversion to open surgery, superficial and deep surgical site infection (SSI), length of stay (LOS) and 30-day re-admission rates. Results Of 1131 patients included, 57.4% were male, 80.5% were laparoscopic, with 7.3% converted to open, 10.8% performed open, and 1.5% by laparotomy. Mean LOS was 3.81 (SD4.0) days, 6.3% readmission rate, with 2.3% superficial SSI and 5.0% deep SSI. ALP was higher in patients with superficial SSI (p < 0.001). Lower ALT was associated with wound dehiscence (p < 0.001). Bilirubin, AST and ALT were lower in patients with chest infections (p < 0.001). ALP correlated with increased LOS (p < 0.001). On multivariable regression, ALP was associated with superficial SSI (p < 0.001), and LOS (p < 0.001). ROC curve analysis demonstrated AUC of 0.655 for ALP and superficial SSI. Conclusions Emergency appendicectomy is completed laparoscopically in more than 80% of patients and complication rates are acceptable. Routine liver function tests were associated with important clinical outcomes including superficial SSI, wound dehiscence, chest infection, LOS and readmission rate. Patients who had superficial SSI, wound dehiscence, chest infection and readmission with 30 days had lower transaminase levels compared with those with uncomplicated recovery.

P-O11 Surgical Ambulatory Care: Reducing surgical admissions whilst maintaining patient satisfaction. Experiences over a four year period

Background The tri-association document; The future of Emergency General Surgery (2015) has a number of key recommendations for the provision of emergency general surgical care. Key recommendations include for senior surgeons to triage referrals and to utilise a “hot clinic” model. Prior to 2016 in the authors’ hospital, all General Practitioner/community referrals were formally admitted to General Surgery. A consultant led ambulatory clinic with dedicated Advanced Nurse Practitioner support was instituted in October 2016. It offers preliminary assessment, phlebotomy and priority access to routine imaging modalities. The clinic is located in a tertiary hospital serving a population of 500,000. Methods A retrospective audit of prospectively collected referral and outcome lists for the Surgical Ambulatory clinic was conducted for the time periods of October 2016 to June 2021. The two primary outcomes were defined as admission to the General Surgical ward and discharge to the community/non-general surgical specialty. Secondary outcomes for patient satisfaction were measured by randomly distributing over a six week period a patient satisfaction survey. The survey was designed in accordance with trust guidance, was anonymous and would cover multiple lead Consultant encounters as a cohort. Results In total, 9069 patients presented to the surgical ambulatory clinic over a period of 44 months. 2347 (26%) were admitted to the General Surgical ward whilst 6717 (74%) were discharged directly from the clinic. 71% of survey responders rated their experiences of the ambulatory clinic as “Excellent”, 19% “Very Good”, 0.5% “Good” and 0.5% “Poor.” Conclusions The introduction of an ambulatory care model has demonstrated a marked reduction in surgical admissions whilst remaining favourable to the patient populace. This has a direct impact on overall bed occupancy rates. In the age of COVID-19, efforts must me made to reduce the the number of potential inpatient interactions to protect those most at risk. A reduced admission and bed occupancy rate will contribute to the reduction of this risk.

Post-COVID-19 vaccination occurrence of splenic infarction due to arterial thrombosis

We present the case of an 82-year-old woman admitted to a regional emergency general surgery centre with severe left upper quadrant abdominal pain and tenderness within 21 days of receiving the first dose of the ChAdOx1 nCov-19 vaccine (Vaxzevria, AstraZeneca). Following further investigation through CT imaging, a thrombus was discovered in the patient’s splenic artery resulting in a large splenic infarct. Splenic infarcts are rare and it is important to note the association between time of administration of the first dose of vaccine and the occurrence of thromboembolic complications in the noted absence of other risk factors for this condition. We hypothesise a link between Vaxzevria vaccine injection and a rare form of thromboembolic complication: thrombosis of the splenic artery.

P-EGS09 The Introduction of an Ambulatory Surgical Pathway

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.

Seropositivity of Hepatitis B & C Virus in Surgical Patients Undergoing Elective & Emergency General Surgery

Aim: To assess the seropositive cases of hepatitis B & C in surgical patients admitted for both emergency & elective surgery. Methodology: This study was conducted in the surgery department of Pak Red Crescent Teaching Hospital. The design of the study was descriptive observational. All the 1238 patients undergoing emergency and elective surgery were enrolled in this study by convenient sampling. Demographic data of all the patients were recorded. Along with routine preoperative tests, all the patients were screened for hepatitis B & C virus infection. Immunochromatography (ICT) method was adopted for both HBsAg and Anti-HCV screening. In patients with week positive results further test of enzyme-linked immunosorbent assay (ELISA) was performed. Operation theater staff and surgeon were informed about seropositive patients to take special precautionary measures during handling of the sharp objects. Biological waste of such patients is disposed of by using Biosafety protocols. Demographic data along with risk factors, HbsAg & Anti-HCV status were collected and analyzed with Microsoft Excel 2019. Results: A total number of 1238 patients were enrolled in our study, out of them 708 were male and 530 were female. Average age of the patients was 40.05±16 years. Out of 1238 patients, HBV was found in 14(1.13%) patients and HCV was found in 121 (9.77%) patients both hepatitis B & C was found in 3(0.24%) patients. Conclusion: Preoperatively screening of hepatitis B and C should be performed mandatory in all patients regardless of the nature of surgery. Before operating seropositive patients, surgeon and operation theater staff should be informed to take precautionary measures while handling the sharp objects. Used infected material of such patients should be disposed of by using Biosafety protocols. All the health works must be vaccinated against hepatitis B virus. Keywords: Hep B infection, Hep C Infection, Seropositive.

Improving Outcomes for Elderly Patients Following Emergency Surgery: a Cutting-edge Review

Purpose of Review The aim of this review is to explore the consequence of emergency general surgery in the elderly, and to summarise recent developments in the pre-, peri- and postoperative management of these patients, in order to improve outcomes. Recent Findings Preoperatively, accurate risk assessment is vital to ensure the right patients undergo emergency surgery. Perioperatively, there are multiple interventions specific to elderly patients that have been shown to improve outcomes. Postoperatively, elderly patients must be cared more in an appropriate setting in order to avoid failure to rescue and promote return to function. Summary This review of contemporary evidence identifies multiple pre-, peri- and postoperative interventions that can improve outcomes for elderly patients after emergency general surgery. These evidence-based recommendations should help direct care of elderly patients undergoing emergency surgery and foster further quality improvement measures and research investigations.