Institutionen för klinisk forskning och utbildning, Södersjukhuset / Department of Clinical Science and Education, Södersjukhuset
Abstract
The overall objective of this thesis was to evaluate the effects of
bedside surgeon-performed ultrasound on the diagnostic accuracy and
management of the patient admitted to the emergency department for
abdominal pain.
Methods
We randomized 800 patients who attended the emergency department at
Stockholm South General Hospital, Sweden, for abdominal pain, to either
receive or not receive surgeon-performed ultrasound as a complement to
routine management. The patients were followed up by a telephone
interview after six weeks and by a registry follow-up after two years.
Outcome measures included proportion of correct diagnoses, the number of
complementary investigations, admission rate, time for surgery if
required, time consumption at the emergency department and at hospital if
admitted, self-rated patient satisfaction at the Emergency Department and
at follow-up, health condition at follow-up, health consumption and
mortality at six week and two year follow-up. Diagnostic accuracy and
need of further examinations and admissions were measured in specific
subgroups as well as timing of surgery among patients with peritonitis.
Results
Several benefits were seen in the group receiving US. Diagnostic accuracy
was significantly higher in the group examined with ultrasound (65%
versus 57%, p=0.027). The number of ordered complementary US examinations
was considerably higher in the group who did not receive bedside US (9%
versus 28%, p < 0.001). The admission rate was lower in the ultrasound
group (43% versus 50%, p = 0.04) and the proportion of patients requiring
surgery submitted for surgery directly from the emergency department was
higher in the ultrasound group (34% versus 16%, p = 0.01). Self-rated
patient satisfaction was slightly higher in the ultrasound group when
leaving the emergency department but equal after six weeks. There was no
difference found in the two-year health consumption or mortality between
the groups.
Regarding sub group analyses increased diagnostic accuracy of bedside US
was seen in the patients with Body Mass Index>25(67% versus 54%, p=0.02),
elevated C-reactive protein (63% versus 52%,p=0.047), peritonitis (74%
versus 54%, age 30-59 years(68% versus 58%, p=0.042) and/or upper
abdominal pain(72% versus 52%, p=0.045). Other benefits such as decreased
need of further examinations and/or fewer admissions were seen in all
groups except the patients with a first diagnosis of appendicitis where
the outcomes were equal between the intervention groups. Among patients
with peritonitis admitted for surgery the decision about surgery was
taken while still at the emergency department for 61 % in the ultrasound
group and 19 % in the control group, p= 0.003.
Conclusion
The results we have shown in our large randomized study, following up
patients on a short- and long-term basis, is that US performed bedside by
the surgeon on duty when a patient seeks care for abdominal pain, can
increase diagnostic accuracy, decrease the need of further examinations,
decrease admission frequency and increase self-rated patient
satisfaction. There are benefits of different kinds in nearly all
subgroups and the health consumption and mortality on a long term basis
are equal. The method is well worth recommending for implementation as a
routine for evaluation of the acute abdomen in the ED