Assessment Strategy for Implementation of Evidence-Based Protocol for Antibiotics in Appendicitis

Introduction: Evidence-based protocols (EBP) exist to guide clinicians in decision-making, however, EBP are often delayed and not optimally implemented [1]. Antibiotic stewardship is heavily guided by EBP and highly relevant to surgical practice. Antibiotic regimens for one of the most common surgical diseases, acute appendicitis (AA) can be highly variable. Post-operative antibiotic (POA) use in non-perforated AA has been largely shown to be non-beneficial and potentially harmful [2]; 4 days of POA in cases where source control is obtained has shown to be non-inferior to commonly prescribed longer courses [3]. We identified lack of consistent antibiotic usage for AA at our academic institution, driving development of an assessment strategy for implementation of an EBP for antibiotic use on the acute care surgical (ACS) service. Methods: Literature review was used to develop an EBP for antibiotic use for AA. Notable aspects of the protocol involved the development of a classification system to aid in more objective reporting of adequacy of source control, a known factor that guides the duration of antibiotic therapy. An assessment strategy was designed characterizing historical practice patterns and the development of a data structure to classify patient outcomes, including complications related to prolonged or unneeded antibiotic use. An education process was designed to inform the ACS staff of the EBP, including a strategy for prospective assessment of its implementation. Results: Based on historical case volume for appendectomies an 18 month pre- and post-adoption interval was chosen for assessment. The data fields for patient characteristics were guided by the developed EBP, specifically noting: status of the appendix (inflamed, gangrenous, perforated), complicating features of operation, duration of the operation, and degree of source control (localization/extent of pus, residual amount of fibrinous exudate). Outcome measures include rates of surgical site infection, recurrent intra abdominal infection, readmission, reoperation, and duration of hospital course. Given the degree of detail needed to categorize degree of source control for the newly implemented EBP, we are unable to retrospectively assess historical compliance, therefore assessment of efficacy of the EBP will focus on outcome measures. Conclusion: Although the goal of EBP is improvement in patient care, this goal cannot be met without implementation, which has historically been delayed and suboptimal. Formal categorization of patient condition based on measurable metrics can help to place them on an appropriate treatment trajectory, which we hypothesize will lead to shorter antibiotic duration and fewer associated complications. Additionally, provider education and awareness surrounding EBP implementation can help to improve compliance. 1. BMC Psychology 2015; 3:32. 2. J Am Coll Surg 2011;213(6):778‐783. 3. NEJM 2015; 372:1996-2005

Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study.

OBJECTIVES: There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. METHODS: A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. RESULTS: A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). CONCLUSION: NOM of grade I-II splenic injuries with CB fails in 20% of patients. LEVEL OF EVIDENCE: IV