Reliability in the process of care during emergency general surgical admission: a prospective cohort study

Introduction Emergency general surgery (EGS) is responsible for 80–90% of surgical in-hospital deaths and the early management of these unwell patients is critical to improving outcomes. Unfortunately care for EGS patients is often fragmented and important care processes are frequently omitted. Methods This study aimed to define a group of important processes during EGS admission and assess their reliability. Literature review and semi-structured interviews were used to define a draft list of processes, which was refined and validated using the Delphi consensus methodology. A prospective cohort study of the 22 included processes was performed in 315 patients across 5 acute hospitals. Results Prospective study of the 22 selected processes demonstrated omission of 1130/5668 (19.9%) processes. Only 6 (1.9%) patients had all relevant processes performed correctly. Administration of oxygen to hypoxic patients (82/129, 64%), consultant review (202/313, 65%) and administration of antibiotics within 3 h for patients with severe sepsis (41/60, 68%) were performed particularly poorly. There were significant differences in the mean number of omissions per patient between hospitals (ANOVA: F = 11.008, p < 0.001) and this was strongly correlated with hospitals' median length of stay (Spearman's rho = 0.975, p = 0.005). Conclusions Reliability of admissions processes in this study was poor, with significant variability between hospitals. It is likely that improvements in process reliability would enhance EGS patients' outcomes. This will require engagement of the entire surgical team and the implementation of multiple interventions to improve the effectiveness of the admission phase of care

Reliability in the process of care during emergency general surgical admission: a prospective cohort study

Introduction Emergency general surgery (EGS) is responsible for 80–90% of surgical in-hospital deaths and the early management of these unwell patients is critical to improving outcomes. Unfortunately care for EGS patients is often fragmented and important care processes are frequently omitted. Methods This study aimed to define a group of important processes during EGS admission and assess their reliability. Literature review and semi-structured interviews were used to define a draft list of processes, which was refined and validated using the Delphi consensus methodology. A prospective cohort study of the 22 included processes was performed in 315 patients across 5 acute hospitals. Results Prospective study of the 22 selected processes demonstrated omission of 1130/5668 (19.9%) processes. Only 6 (1.9%) patients had all relevant processes performed correctly. Administration of oxygen to hypoxic patients (82/129, 64%), consultant review (202/313, 65%) and administration of antibiotics within 3 h for patients with severe sepsis (41/60, 68%) were performed particularly poorly. There were significant differences in the mean number of omissions per patient between hospitals (ANOVA: F = 11.008, p < 0.001) and this was strongly correlated with hospitals' median length of stay (Spearman's rho = 0.975, p = 0.005). Conclusions Reliability of admissions processes in this study was poor, with significant variability between hospitals. It is likely that improvements in process reliability would enhance EGS patients' outcomes. This will require engagement of the entire surgical team and the implementation of multiple interventions to improve the effectiveness of the admission phase of care

Appendicitis risk prediction models in children presenting with right iliac fossa pain (RIFT study): a prospective, multicentre validation study.

Background Acute appendicitis is the most common surgical emergency in children. Differentiation of acute appendicitis from conditions that do not require operative management can be challenging in children. This study aimed to identify the optimum risk prediction model to stratify acute appendicitis risk in children. Methods We did a rapid review to identify acute appendicitis risk prediction models. A prospective, multicentre cohort study was then done to evaluate performance of these models. Children (aged 5\u201315 years) presenting with acute right iliac fossa pain in the UK and Ireland were included. For each model, score cutoff thresholds were systematically varied to identify the best achievable specificity while maintaining a failure rate (ie, proportion of patients identified as low risk who had acute appendicitis) less than 5%. The normal appendicectomy rate was the proportion of resected appendixes found to be normal on histopathological examination. Findings 15 risk prediction models were identified that could be assessed. The cohort study enrolled 1827 children from 139 centres, of whom 630 (34\ub75%) underwent appendicectomy. The normal appendicectomy rate was 15\ub79% (100 of 630 patients). The Shera score was the best performing model, with an area under the curve of 0\ub784 (95% CI 0\ub782\u20130\ub786). Applying score cutoffs of 3 points or lower for children aged 5\u201310 years and girls aged 11\u201315 years, and 2 points or lower for boys aged 11\u201315 years, the failure rate was 3\ub73% (95% CI 2\ub70\u20135\ub72; 18 of 539 patients), specificity was 44\ub73% (95% CI 41\ub74\u201347\ub72; 521 of 1176), and positive predictive value was 41\ub74% (38\ub75\u201344\ub74; 463 of 1118). Positive predictive value for the Shera score with a cutoff of 6 points or lower (72\ub76%, 67\ub74\u201377\ub74) was similar to that of ultrasound scan (75\ub70%, 65\ub73\u201383\ub71). Interpretation The Shera score has the potential to identify a large group of children at low risk of acute appendicitis who could be considered for early discharge. Risk scoring does not identify children who should proceed directly to surgery. Medium-risk and high-risk children should undergo routine preoperative ultrasound imaging by operators trained to assess for acute appendicitis, and MRI or low-dose CT if uncertainty remains. Funding None